Effect of phenytoin on collagen accumulation by human gingival fibroblasts exposed to TNF-alphain vitro

OBJECTIVE

Tumor necrosis factor (TNF)-alpha is associated with chronic gingival inflammation and reported to induce gingival overgrowth (GO), while phenytoin (PHT) is also known to be a causative agent of GO. We examined the synergistic effect of PHT and TNF-alpha on collagen metabolism in human gingival fibroblasts (HGFs).

MATERIALS AND METHODS

HGFs were cultured with TNF-alpha and PHT. Quantitative real-time RT-PCR was employed to determine the mRNA levels for collagen, matrix metalloproteinases (MMPs), tissue inhibitors of metalloproteinases (TIMPs) and integrin subunits. Cellular collagen endocytosis was determined using a flow-cytometry.

RESULTS

The proliferation of HGFs was not affected by TNF-alpha or PHT individually, whereas both synergistically increased collagen accumulation in HGFs. Further, collagen mRNA expression was not increased by TNF-alpha or PHT, although together they markedly prevented cellular collagen endocytosis, associated with the suppression of alpha2beta1-integrin mRNA expression. The mRNA expression of MMP-1 and-2 was suppressed by PHT, while TIMP-1 mRNA expression was enhanced by both TNF-alpha and PHT.

CONCLUSION

Our results suggest that TNF-alpha and PHT together cause impaired collagen metabolism by suppression of enzymatic degradation with MMPs/TIMP-1 and integrin-mediated endocytosis. These synergistic effects may also be involved in TNF-alpha- and PHT-induced collagen accumulation, leading to GO.

Relationship of periodontal bacteria and Porphyromonas gingivalis fimA variations with phenytoin-induced gingival overgrowth

OBJECTIVES

We investigated the relationship between phenytoin-induced gingival overgrowth (GO) and the harboring of periodontal bacteria.

MATERIALS AND METHODS

Periodontal conditions and subgingival bacterial profiles were examined in 450 sites of 75 subjects. A polymerase chain reaction method was used to detect six bacterial species; Porphyromonas gingivalis (Pg), Actinobacillus actinomycetemcomitans (Aa), Tannerella forsythia, Treponema denticola (Td), Prevotella intermedia (Pi), and Prevotella nigrescens (Pn). Genetic variations of the Pg fimA gene were also examined. Bacterial occurrence was compared with the severity of GO, and alterations in the bacterial occurrence rate and quantities were monitored following periodontal treatment.

RESULTS

The occurrences of Aa, Td, Pi, Pn, and Pg with type II fimA (type II Pg) were significantly associated with the severity of GO. Td occurrence was reduced in association with gingival improvement following ultrasonic scaling, however, no such relationship was observed with Aa, Pi, Pn, and Pg. In addition, Pg and Pi markedly persisted after treatment. Clinical improvement of the sites, following an Er:YAG laser treatment, significantly associated with quantitative reduction of Pg in improved sites, however, not that of Pi.

CONCLUSION

Type II Pg and Td were each found to have a significant relationship with the development and deterioration of GO.

Alterations of phosphorylation state of connexin 43 during hypoxia and reoxygenation are associated with cardiac function

Gap junctions formed by connexins mediate cell-cell communication by electrical and chemical coupling. Recently, it has been shown that alterations in the phosphorylation state of the connexins result in functional alteration of cell-cell communication through gap junctions. Therefore, we focused on the association of alterations of phosphorylation state of connexin 43 (Cx43) with cardiac function in vivo. Rat hearts were transferred to Langendorff apparatus and submitted to hypoxia and then reoxygenated. In the control heart, Cx43 was phosphorylated and located at the intercalated disk. When the hearts were subjected to hypoxia, Cx43 at gap junctions was dephosphorylated and changed its localization to the entire plasma membrane. The area of cardiomyocytes stained with anti-phosphorylated Cx43 antibody was decreased in a time-dependent manner. Immunoblot data supported the decrease of phosphorylated Cx43 during hypoxia. ZO-1 did not change its localization at the intercalated disk during the hypoxic period. We also found that the area occupied by dephosphorylated Cx43 was correlated with the decrease of percent of rate-pressure product. These data indicate that dephosphorylation and redistribution of Cx43 is an early sign of cardiac injury after hypoxia. Detection of dephosphorylated Cx43 may serve as a diagnostic tool for examining ischemic heart disease.

The human relaxin receptor (LGR7): expression in the fetal membranes and placenta

The relaxin receptor has been recently described as a leucine-rich repeat G-protein coupled receptor and designated as LGR7. A closely related receptor, LGR8, is co-expressed by some cells. This study explored the expression of the genes for these receptors in the human fetal membranes and placenta by RT-PCR and the LGR7 protein by immunolocalization. The results showed that LGR7 was well expressed in the fetal membranes, with significantly more in the decidua (p<0.05) than in the amnion. On the other hand, relatively low levels were expressed in the placenta. The major splice variant of LGR7 was undetectable in either the placenta or fetal membranes. Expression of LGR8 was also below the level of detectability in either tissue. Immunostaining for LGR7 was conducted with antisera to both its endodomain and ectodomain, in order to seek evidence for a solubilized ectodomain. However, similar staining patterns were obtained with both antisera, with predominant staining in the cells of the amniotic epithelium, chorionic cytotrophoblast and decidua. Full-thickness fetal membranes from preterm deliveries, before and after labor or after preterm premature rupture of the membrane (PPROM) and labor were collected. In addition, membranes at term, both before and after spontaneous labor were used for analysis of LGR7 gene expression. There was significantly greater LGR7 expressed (p=0.01) in the preterm period compared to term, indicating a potentially important role for relaxin at this time. There was a marginal decline in LGR7 gene expression after labor and delivery both at preterm and term, which did not reach significance. Immunostaining patterns showed less inter-patient variability than did gene expression, with more intense staining for LGR7 after labor and delivery.

[Graft selection in elderly patients undergoing isolated coronary artery revascularization]

Several studies have shown that off-pump coronary artery bypass (OPCAB) in elderly patients is better in terms of postoperative complications and length of hospital stay. We evaluated the outcomes of isolated OPCAB in octogenarians. From June 2002 to December 2004, 26 patients underwent isolated coronary artery bypass grafting (CABG). All patients underwent OPCAB. These included 4 emergency cases and 12 in an urgent situation, so the overall non-elective rate was 61.5%. There was no hospital death or serious complication. The mean number of grafts per patient was 3.2 +/- 1.6, and the complete revascularization rate was 90.4%. All patients received at least 1 arterial conduit, and 16 patients (61.5%) received all arterial grafts. Saphenous vein grafts were used in 10 patients. These values were not significantly different from those in patients in their 70s who underwent CABG during the same period. We conclude that even in high-risk octogenarian patients, with the aid of the off-pump technique, we can safely perform complete revascularization using more arterial conduits with minimal risk.

Systematic off-pump coronary artery bypass

PURPOSE

We assessed the feasibility of systematic off-pump coronary artery bypass (OPCAB) and identified risk factors for on-pump conversion.

METHODS

Between July 1, 2002 and December 31, 2003, OPCAB was attempted for all patients who required isolated coronary artery bypass in our institution. The perioperative results of patients were prospectively entered into a structured database, the results were analyzed to identify the risks of requirement of cardiopulmonary bypass.

RESULTS

OPCAB was performed in all but 4 patients, giving an OPCAB success rate of 98.3% (229/233). The reason for cardiopulmonary bypass was hemodynamic instability occurring during reoperative surgery in 3, and cardiogenic shock in 1. The isolated risk factor for on-pump conversion was reoperation (relative risk 11.6). Mean number of distal anastomoses performed under OPCAB was 3.7+/-1.2, and the complete revascularization rate was 92.1% (211/229). There was one hospital death (0.4%). During a mean follow-up period of 1.0+/-0.4 years, two patients developed angina, which were treated with catheter intervention; otherwise, there was no death, or other cardiac events observed.

CONCLUSION

Systematic OPCAB was feasible except in patients undergoing reoperative surgery or patients with on-going deep cardiogenic shock. Systematic OPCAB provided successful complete revascularization and its short term results were acceptable.

Aortic Nontouch Off-Pump Complete Revascularization Using 3 In Situ Arterial Conduits: Bilateral Internal Mammary Arteries and Gastroepiploic Artery

BACKGROUND

Arterial grafts have been used frequently in recent coronary artery bypass grafting (CABG). Off-pump CABG can facilitate early patient recovery. A combination of in situ graft and off-pump technique results in complete aortic nontouch surgery; however, outcome has not been well established.

METHODS

Between May 1998 and December 2001, 1035 consecutive isolated CABG operations were performed at Juntendo-Shin-Tokyo Hospital Group. Of these, off-pump CABG using in situ bilateral internal mammary arteries and in situ gastroepiploic artery was performed in 48 patients (41 men and 7 women; mean age, 74.5 +/-9.9 years). Perioperative and follow-up data were studied.

RESULTS

The average number of distal anastomoses was 3.4 +/-0.7, and complete revascularization was achieved in all patients. There were no hospital deaths. Perioperative myocardial infarction was observed in 1 patient, congestive heart failure in 1, stroke in 2, and mediastinitis in 1. Postoperative catheterization was performed in 30 patients and revealed no graft occlusions. During the follow-up period of 2.3 +/- 1.2 years, no remote deaths, angina recurrence, or coronary interventions were observed.

CONCLUSION

Off-pump CABG using an all in situ arterial graft can be performed safely, and follow-up results are excellent.

Off-Pump Coronary Artery Bypass Using Skeletonized Gastroepiploic Artery, a Pilot Study

Abstract Background: The problem with using the gastroepiploic artery (GEA)for coronary artery bypass grafting (CABG) is vasospasm. To minimize vasospasm of the GEA, a skeletonized harvesting technique was used for GEA harvesting. We present the initial results of GEA grafting using this technique. Methods: Between September 1, 2002, and December 31, 2002, a total of 25 patients (21 men and 4 women, mean age 65.4 +/- 8.7 years) gave informed consent and underwent elective off-pump CABG using the skeletonized GEA. Skeletonization was completed using an ultrasonic scalpel (Harmonic scalpel, coagulating-scissors; Ethicon Endo-Surgery, Cincinnati, OH, USA). Follow-up data were available until August 31, 2003. Perioperative, early clinical, and follow-up results were analyzed. Results: There were no hospital deaths, perioperative myocardial infarctions, congestive heart failure, strokes, or renal failure. There were no abdominal complications. Follow-up data were available from all patients, with a mean follow-up of 0.8 +/- 0.1 years. There were no cardiac deaths or cardiac events. Conclusion: During our limited follow-up period, the early results of skeletonized GEA grafting were excellent, and cardiac events have been well controlled. Mid-term follow-up study and angiographic study are necessary to confirm our initial clinical outcome data.

Bypass to the Distal Right Coronary Artery Using In Situ Gastroepiploic Artery*

OBJECTIVE

We investigated the clinical outcomes after coronary artery bypass grafting (CABG) using the in situ gastroepiploic artery (GEA) exclusively bypassing to the distal right coronary artery (RCA).

METHODS

Between, 1991 and 2002, 1020 consecutive patients (788 male and 232 female with a mean age of 63.6 +/- 9.7) underwent CABG to the distal coronary artery using in situ GEA in the Shin-Tokyo Hospital Group. Their perioperative and follow-up data were retrospectively analyzed.

RESULTS

The in-hospital morbidity rate was 15.1% and the mortality rate was 0.6%. Postoperative myocardial infarction associated with GEA graft failure occurred in two cases. Among the survivors, follow-up was completed in all patients with a mean period of 4.7 +/- 2.4 years. Actuarial 3- and 5-year angina or intervention-free rates were 93.6% and 89.9%, respectively. Actuarial 3- and 5-year survival rates were 95.8% and 91.6%, respectively. Postoperative angiography was performed on 482 patients within 1 year, 115 patients with 3 years, and in 87 patients more than 4 year after surgery. The GEA patency rates at 1, 3, and 5-year were 95.7%, 90.2%, and 85.7%, respectively. These patency rates were compared with other graft materials (the saphenous vein n = 291, radial artery n = 186, and right internal thoracic artery n = 23) used for bypass to the distal RCA, and we found no significant differences (p = 0.29).

CONCLUSION

The perioperative and clinical remote results of GEA grafting were satisfactory. The angiographic patency rates of GEA to the distal RCA was not inferior to the saphenous vein graft in this study.

Synergistic effect of triptolide and tacrolimus on rat cardiac allotransplantation

Recent studies have shown that triptolide inhibits T cell activation through mechanisms different from those of cyclosporine A and tacrolimus and we postulated that triptolide might have a synergistic effect with tacrolimus to enhance immunosuppression. Using a F344 donor-to-Lewis recipient rat combination, we investigated the immunosuppressive effects of triptolide alone or in combination with tacrolimus on the survival of cardiac allografts. Recipients were treated with placebo, triptolide, tacrolimus, and triptolide in combination with tacrolimus at different doses. The median survival time (MST) was 8 days for placebo; 9.5, 11, 14 and 19 days for triptolide monotherapy at doses of 0.04, 0.08, 0.16, and 0.32 mg/kg/day, respectively, and 11, 13.5, and 52 days for tacrolimus monotherapy at doses of 0.025, 0.05, and 0.1 mg/kg/day, respectively. Tacrolimus 0.025 mg/kg/day combined with triptolide 0.08 and 0.16 mg/kg/day prolonged the MST to 17.5 and 20 days, respectively; while tacrolimus 0.05 mg/kg/day combined with triptolide 0.04, 0.08, and 0.16 mg/kg/day prolonged the MST to 21, 23, and 23 days, respectively. These results suggest that triptolide is a moderately effective immunosuppressive agent. Triptolide combined with a subtherapeutic dose of tacrolimus produced a synergistic effect in prolonging rat cardiac allograft survival.

ONO-4817, a novel matrix metalloproteinase inhibitor, attenuates allograft vasculopathy in a rat cardiac transplant

BACKGROUND

Cardiac allograft vasculopathy (CAV), a disorder characterized by rapid development and progression of obliterative vasculopathy in the transplanted heart, continues to be a major cause of graft failure in long-surviving human transplants. The mechanisms and histopathologic processes of CAV remain unknown. Previous animal studies have shown that inhibition of matrix metalloproteinase (MMP) prevents migration and proliferation of smooth muscle cells in CAV. In this study, we hypothesized that MMPs may be expressed in and may play an important role in CAV.

METHODS

An F344-to-WKAH rat heterotopic heart transplantation model was used. Tacrolimus was administered intramuscularly 14 days after transplantation to prevent acute rejection and to allow the development of CAV. We divided the animals into 2 groups according to post-operative treatment: an ONO group received an MMP inhibitor (ONO-4817) daily by oral gavage for 14 days after transplantation (n = 6), and a control (n = 6) group received no treatment. Grafts were harvested 60 days after treatment.

RESULTS

Immunohistochemical staining revealed that MMP-2 and tissue inhibitors of metalloproteinase-2 (TIMP-2) were expressed more strongly in the neointima and media of the control CAV animals than in the ONO-CAV animals. The animals given ONO-4817 exhibited a significant decrease in the percentage of affected vessels, in the percentage of intimal proliferation, in the intima-to-media ratio, and in the expression of MMP-2 and TIMP-2.

CONCLUSION

These results suggest that MMP-2 and TIMP-2 play an important role in the development of CAV and that the use of an MMP inhibitor (ONO-4817) may prevent neointimal proliferation in patients with CAV.

Skeletonized Radial Artery Grafting: One-Year Patency Rate

BACKGROUND

The skeletonized radial artery harvesting technique has routinely been used in our institute. Its clinical outcome is acceptable; however, the graft patency rate at 1 year has not been reported.

METHODS

Between July 1, 2003, and October 31, 2002, 50 consecutive patients underwent isolated coronary artery bypass using skeletonized radial artery grafts in our hospital. There were no hospital deaths or perioperative myocardial infarctions. All patients completed follow-up by November 2003. Twenty of these patients (18 asymptomatic volunteers and 2 symptomatic patients) underwent coronary angiography at 1 year, and the results were analyzed.

RESULTS

At a mean (+/-SD) follow-up period of 1.2 +/- 0.2 years, there were no deaths. Two patients developed angina due to graft occlusion (1 in the radial artery and another in the gastroepiploic artery). Twenty-one radial artery grafts and 36 distal anastomoses with radial artery grafts were evaluated by angiography at 1 year (0.9 +/- 0.1 years). There was 1 radial artery graft occlusion affecting 1 distal anastomosis, giving a perfect graft patency rate of 95.2% (20/21) and a perfect anastomosis patency rate of 97.2% (35/36). The patient with the occluded radial artery graft had a history of peripheral vascular disease and diabetes. There were no graft stenoses or string signs.

CONCLUSION

At our limited follow-up, the results of using skeletonized radial artery grafts are excellent. Extensive skeletonization will not affect the graft patency rate or early graft spasm. Careful examinations of the radial artery grafts in patients with a history of peripheral artery disease and diabetes are mandated.

Comparison of inflammatory changes caused by Porphyromonas gingivalis with distinct fimA genotypes in a mouse abscess model

The fimA gene of Porphyromonas gingivalis, encoding fimbrillin (a subunit protein of fimbriae) has been classified into six genotypes (types I-V and Ib). The genotypic variation was previously suggested to be related to the severity of adult periodontitis in the general population. In this study, we compared inflammatory changes caused by bacterial infection to study pathogenic heterogeneity among the different fimA strains in a mouse abscess model. Bacterial suspensions of 13 P. gingivalis strains representing the six fimA types were subcutaneously injected into female BALB/c mice, and serum sialic acid concentrations were assayed as a quantitative host inflammatory parameter. Type II fimA organisms caused the most significant induction of serum sialic acid, as well as other infectious symptoms, followed by types Ib, IV and V. In contrast, types I and III caused weak inflammatory changes. In addition, fimA mutants of type II strains clearly lost their infectious ability. These findings suggest that fimA genotypic variation affects expression of P. gingivalis virulence.

Quantitative detection of periodontal pathogens using real-time polymerase chain reaction with TaqMan probes

Quantitative analysis, with identification of periodontopathic bacteria, is important for the diagnosis, therapeutic evaluation and risk assessment of periodontal disease. We developed a highly sensitive and specific method using real-time polymerase chain reaction (PCR) to detect and quantify six periodontal bacteria: Porphyromonas gingivalis, Tannerella forsythia, Actinobacillus actinomycetemcomitans, Treponema denticola, Prevotella intermedia, and Prevotella nigrescens. Species-specific TaqMan probe/primer sets were designed according to 16S ribosomal RNA gene sequences. Plaque and tongue debris specimens were collected from 10 patients with advanced periodontitis and 10 periodontal healthy individuals and analyzed. All species, except for P. nigrescens, were detected in samples from diseased sites in significantly greater numbers than in those from healthy sites, whereas greater numbers of P. nigrescens were found in the controls. These results suggest that the present real-time PCR method with the designed probe/primer sets enabled sensitive detection of the six periodontal bacteria, and may also assist future microbial studies of periodontal diseases.

Skeletonized Gastroepiploic Artery for Off-Pump Coronary Artery Bypass Grafting

BACKGROUND

Skeletonized arterial grafting may reduce the risk of graft spasm and may improve graft patency. Previously we reported a pilot study of skeletonized gastroepiploic artery (GEA) grafting with favorable results. Skeletonized GEA harvesting with an ultrasonic scalpel has now become our routine procedure. In this report, we compare the early clinical outcomes of skeletonized versus pedicled GEA grafting to assess the safety and benefit of use of skeletonized GEA in coronary artery bypass grafting.

METHODS

Between July 2002 and October 2003, the GEA was used as a conduit for isolated off-pump coronary artery bypass grafting in 105 patients. Of these, 21 patients (group P) received pedicled GEA and 59 patients (group S) received skeletonized GEA grafts (excluding 25 patients whose results were reported in the pilot study). The perioperative and early follow-up data were prospectively collected and compared.

RESULTS

No graft injury was found in either group. The preoperative characteristics were similar in the two groups except that group S had a smaller body surface area (1.64 +/- 0.16 m 2 in group S versus 1.73 +/- 0.16 m 2 in group P, P <.05) and a significant number of patients with diabetes (36/59, 61.0% versus 7/21, 33.3%, P <.05). The number of distal anastomoses was 4.3 < 1.0 versus 3.9 +/- 0.9 ( P = not significant [NS]). An in situ GEA composite graft was constructed in 8 (13.6%) of the patients in group S and none of the patients in group P ( P = NS). There was one hospital death due to infection in group S. Otherwise, there were no cases of low output syndrome or postoperative myocardial infarction in either group. During early postoperative follow-up, no angina recurrence or myocardial infarction was found.

CONCLUSION

The GEA can be skeletonized safely with an ultrasonic scalpel. Skeletonization enables a wider variety of choices in the use of GEA grafting.

Redo coronary artery bypass grafting: early and mid-term results

OBJECTIVES

Redo coronary artery bypass grafting (CABG) has been gradually increasing in Japan. We prospectively collected redo-CABG data and evaluated these the early and remote results.

METHODS

Between 01/01/1994 and 06/30/2002, a total of 71 patients underwent isolated redo-CABG in our hospital group. The interval between operations was 7.8 +/- 6.1 years. Previous surgery was CABG in all patients. Perioperative, early angiographic, and follow-up results were analyzed.

RESULTS

The mean number of grafts was 2.9 +/- 1.2. There were 4 incidences of injury to the heart or graft during sternal re-entry or during dissection of the heart. There was 1 hospital death (2.8%) and 19 major complications (26.8%), including 7 patients (9.9%) with postoperative congestive heart failure and 2 (2.8%) with postoperative myocardial infarction. Postoperative angiography was obtained in 47 patients and their overall stenosis free patency rate was 93.9%. Follow-up was completed for all hospital survivors with a mean follow-up of 3.9 +/- 2.2 years. The event-free and survival rates at 5 years were 76.4% and 83.9%, respectively.

CONCLUSION

In our limited experience, redo-CABG was performed with acceptable risks and its long-term results were satisfactory.

Skeletonization of the radial artery with the ultrasonic scalpel: clinical and angiographic results

BACKGROUND

To improve the patency rate of the radial artery graft, we have been using a skeletonized harvesting technique since September 1, 2001. Our early reports confirmed better graft patency of the skeletonized radial graft than the conventional pedicled graft. However, its midterm results were unknown. We present our recent experience and follow-up results of radial artery grafting using the skeletonized harvesting technique.

METHODS

Between September 1, 2001, and July 31, 2002, 391 patients underwent isolated coronary artery bypass surgery in our hospital group, excluding minimally invasive direct coronary bypass procedures via small thoracotomy or T-grafting. Among them, skeletonized radial grafting was performed in 246 patients (182 men and 64 women; mean age, 66.2 +/- 9.5 years). Follow-up is to be completed by December 31, 2003. Perioperative, early angiographic, and follow-up results were analyzed.

RESULTS

There were 1 hospital death and 5 incidences of postoperative myocardial infarction. None of these occurrences were related to radial artery bypass. Early angiography revealed that the stenosis-free graft patency rate of radial artery anastomoses (291/303 cases, 96.0%) was not significantly different from the patency rates of surgeries involving the use of other conduits (left internal mammary artery, 95.1%; right internal mammary artery, 93.8%; gastroepiploic artery, 93.1%; and saphenous vein, 98.2%). Follow-up was completed for all hospital survivors with a mean follow-up time of 1.4 +/- 0.3 years. There were no cardiac deaths and 5 cardiac events, giving a cardiac event-free rate of 97.5%.

CONCLUSION

In our limited follow-up, cardiac events have been well controlled. Midterm follow-up angiographic study is necessary to confirm our clinical outcome data.

Venous coronary artery bypass grafting: late results of a 15-year actuarial follow-up in 486 patients

PURPOSE

The aim of this study was to clarify the long-term results of venous coronary artery bypass grafting in Japanese patients.

METHODS

The study population included 492 patients who underwent venous coronary artery bypass procedures at the Department of Cardiothoracic Surgery of Juntendo University from January 1984 to December 1989. The great majority of patients, 420 of 492 (85.4%), were males, and the mean patient age was 61.1 years (range: 32-82 years). The disease conditions included single-vessel disease in 32 patients (6.5%), double-vessel disease in 111 patients (22.6%), triple-vessel disease in 251 patients (51.2%), and 50% or more stenosis of the left main coronary artery in 98 patients (19.9%). A mean of 2.4 grafts was used per patient.

RESULTS

The 15-year survival rate was 57.7%. The 15-year actuarial cardiac survival and cardiac event-free survival were 81.3% and 51.3%, respectively. The 15-year actuarial freedom from reoperation and myocardial infarction were 87.5% and 92.1%, respectively. Of 192 patients who died during the follow-up period, 62 deaths were due to cardiac causes (32.3%), 43 were due to malignant neoplasms (22.4%), and 25 were due to cerebral vascular accidents (13.0%).

CONCLUSION

The prognosis of Japanese patients undergoing coronary artery bypass grafting may therefore be more favorable than that of Western patients. In addition, diabetes mellitus was an independent risk factor for both cardiac death and cardiac events.

[Procedure and problem for short-term outcomes on off-pump coronary artery bypass grafting]

We performed off-pump coronary artery bypass grafting (CABG) in all cases without reoperation case from July, 2002. Advantage of off-pump CABG versus on-pump CABG which is reduced a number of perioperative complication and early patients recovery was previously demonstrated. In our institute, the mean number of grafts per patients was 4.7 +/- 1.3, and the rate of using arterial grafts was 99.5% in all cases without minimally invasive direct coronary artery bypass (MIDCAB). The mean hospital stay after operation was 10.8 +/- 2.8. It was shorted remarkably in comparison with on-pump CABG; 19.4 +/- 6. Furthermore, sever complication was not occurred in any cases after operation though high risk cases were increased. In the early cases, atrial fibrillation complicated frequently (32%), but using after magnesium sulfate it was remarkably decreased (8.4%). On the other-hand, attention is necessary for the infection caused by the increase of high risk patients. Therefore, we used vancomycin (VCM) at these cases from the viewpoint of prevention. Recently, we performed remnant omental transfer for the sever diabetes mellitus case which was used bilateral internal thoracic artery on CABG. It learned to get the early recovery which was necessary for the off-pump CABG by the above additional treatment.

Off-pump multivessel revascularization: efficacy of suction type of coronary stabilizer

OBJECTIVE

Off-pump coronary artery bypass grafting (CABG) has come into widespread use with the availability adequate coronary stabilization devices. We studied the efficacy of second-generation coronary stabilization devices (suction device) comparing to the first-generation device (compression device).

METHODS

We prospectively analyzed consecutive patients who underwent isolated off-pump CABG via a midline sternotomy at Shin-Tokyo Hospital Group between July 1, 1996, and August 31, 2000, comparing perioperative, and follow-up data in the group using a suction device (group S) to that in the group using a compression device (group C).

RESULTS

Preoperative risk factors were identical between the two groups, with the exception of a higher incidence of three vessel disease in group S. Complete revascularization increased from 47.3% in group C to 88.1% in group S, and the number of distal anastomoses from 2.1 +/- 0.6 in group C to 2.9 +/- 0.9 in group S. Revascularization of the circumflex artery was achieved in 21.7% of group S patients, which was significantly higher than that in group C (2.2%). Postoperative recovery, mortality, and morbidity did not differ significantly between groups. Calculated event-free rates at 2 years was 88.7% in group C and 92.0% in group S (p = NS).

CONCLUSIONS

Anastomosis to the posterior wall of the heart using the suction device is safe. An increased number of distal anastomoses may reduce the occurrence of cardiac events related to incomplete revascularization.

Coronary artery bypass grafting for patients with poor left ventricular function

Patients undergoing isolated first-time elective coronary bypass surgery were classified according to their preoperative ejection fraction: group 1 comprised 131 patients with poor left ventricular function (ejection fraction < 40%); group 2 was 1,496 control patients. The mean number of distal anastomoses was not significantly different in the 2 groups, however, clamp time, pump time, and operative time were longer in group 1. Patient recovery was significantly slower in group 1. Morbidity (14.5% in group 1 versus 7.4% in group 2, p < 0.005) and mortality (2.3% versus 0.1%, p < 0.0001) were higher in group 1. During late follow-up, the 5-year survival rate (70.1% versus 90.5%) and 5-year event-free rate (65.6% versus 81.9%) were significantly inferior in group 1 compared to group 2. The results of bypass surgery in cases of decreased left ventricular function were poor, and such patients need to be carefully followed up.

Minimally invasive direct coronary artery bypass: current experience

BACKGROUND

Minimally invasive direct coronary artery bypass (MIDCAB) via a small incision has been performed for revascularization of the left anterior descending artery with the left internal mammary artery. In this study, we analyzed outcome in patients who underwent MIDCAB.

METHODS

Between June 1997 and July 2002, a total of 125 patients (96 men and 29 women; mean age, 65.1 +/- 9.6 years) underwent MIDCAB. Perioperative and follow-up data were entered into a structured database.

RESULTS

Coronary anastomosis time was 17.0 +/- 5.0 minutes. Mean intubation period, intensive care unit stay, and postoperative hospital stay were 4.0 +/- 2.8 hours, 1.3 +/- 0.8 days, and 9. 7 +/- 4.6 days, respectively. There were no hospital deaths or cases of postoperative heart failure, myocardial infarction, renal failure, prolonged ventilation (>2 days), or stroke. During the follow-up period of 3.3 +/- 1.5 years, 12 patients developed angina, and there were 10 deaths. The actuarial 3-year survival rate was 92.6%, and the event-free rate was 87.1%.

CONCLUSION

MIDCAB can be performed with early recovery with minimum mortality and morbidity. The longterm results after MIDCAB are acceptable.

Concomitant cholecystectomy and coronary artery bypass

INTRODUCTION AND METHODS

Cholelithiasis is a common disorder which may be present with coronary artery disease. Concomitant cholecystectomy and coronary artery bypass grafting (CABG) was performed in selected patients and retrospective study was performed to verify the safety of the concomitant surgery.

RESULTS

A total of 55 patients (41 males and 14 females, mean age 64.6 8.7 years) underwent concomitant cholecystectomy and CABG between 1992 and 2001 at the Shin-Tokyo Hospital Group. Exclusion from concomitant surgery was choledocholithiasis and/or acute cholecystitis. Cholecystectomy was performed via an upper abdominal incision extending the mid-sternal incision. In 48 patients (87.3%), the gastroepiploic artery (GEA) was used for coronary revascularization. The mean number of bypass grafts was 3.6 1.2. The mean operative time, intubation period, ICU stay, and postoperative hospital stay were 376 minutes, 15.6 hours, 3.9 days, and 23.0 days, respectively. Postoperative feeding was resumed 1 day after extubation. No intra-abdominal complications, delays in feeding, abdominal wound complications or postoperative bowel obstruction were observed.

CONCLUSIONS

Concomitant surgery of cholecystectomy and CABG did not increase the postoperative complications, and it is a feasible procedure of choice.

Identification of a new variant of fimA gene of Porphyromonas gingivalis and its distribution in adults and disabled populations with periodontitis

Porphyromonas gingivalis fimbriae are critical for the promotion of bacterial infection. The fimA gene encoding fimbrillin, a subunit of fimbriae, has been classified into five genotypes (types I to V) based on their nucleotide sequences. Using a fimA type-specific PCR assay, our previous study demonstrated a close relationship between P. gingivalis possessing type II and type IV fimA genes and adult periodontitis. In that study, some clinical specimens were found to be positive for both types I- and II- fimA specific primers, likely due to the coexistence of two clonal types or a single clone of an unknown genotype in the samples. In the present study, we cloned a new variant of the fimA gene, designated as type Ib fimA, from P. gingivalis HG1691. The nucleotide sequence of the cloned fimA gene showed a 97.1% homology with that of type I fimA, indicating it as a clonal variant of type I fimA. Organisms with type Ib fimA were detected in 13.5% of periodontitis patients and in 2.9% of periodontal healthy adults. Statistical analysis revealed a strong relationship between periodontitis and specific fimA types such as type Ib [odds ratio (OR) 6.51], type II (OR 77.8), and type IV (OR 7.54). Moreover, type Ib fimA-organisms were also found to be related to periodontitis in Down's syndrome (OR 1.91) and mentally disabled populations (OR 4.00). These findings suggest that P. gingivalis with type Ib fimA is closely associated with the progression of periodontitis, similar to organisms with type II and IV fimA.

Coronary artery bypass grafting in patients on chronic hemodialysis: diabetic nephropathy versus nondiabetic nephropathy

Patients with both end-stage renal disease and diabetes mellitus carry an increased risk of coronary atherosclerosis. This study was performed to evaluate the perioperative and remote outcome of diabetic nephropathy patients on hemodialysis undergoing coronary artery bypass grafting (CABG). We retrospectively analyzed the results of CABG performed between September 1, 1993 and August 31, 2001. Preoperative, perioperative, and follow-up data of patients with hemodialysis primarily due to diabetic nephropathy (Group D, n = 31, 22 males and 9 females with a mean age of 60.1 +/- 6.6) were collected and compared to patients with hemodialysis primarily due to nondiabetic nephropathy (group N, n = 21, 17 males and 4 females with a mean age of 60.9 +/- 11.2). Preoperative risk factors between the 2 groups were not significantly different. The mean number of distal anastomoses was 2.5 +/- 1.2 in Group D and 2.5 +/- 1.0 in Group N (p = not significant [NS]). All patients received at least 1 internal mammary artery graft. There was 1 in-hospital death in each group. Postoperative recovery, mortality, and morbidity were not significantly different between the two groups. At the mean follow-up of 2.7 years, the actuarial 3 year survival rate was 72.8% in Group D and 78.7% in Group N (p = NS). The actuarial 3 year cardiac event-free rate was 79.7% in Group D and 74.7% in Group N (p = NS). CABG for hemodialysis patients can be performed with acceptable risks. Diabetic nephropathy has no impact on early or remote patient outcomes among patients on hemodialysis.

Skeletonized radial artery grafting: improved angiographic results

BACKGROUND

The radial artery has been used for coronary artery bypass grafting (CABG) but its early angiographic results were relatively inferior to that of the internal mammary artery, most likely due to spasm of the graft. To avoid vasospasm we harvested the radial artery using a skeletonized technique and spasm was completely reversed before use. The graft patency of the skeletonized radial artery was compared with the radial artery graft harvested as a pedicle.

METHODS

A total of 112 patients underwent isolated CABG using a pedicled radial artery between September 1, 1999, and August 31, 2000 (group P), and a total of 131 patients with a skeletonized radial artery between September 1, 2000, and August 31, 2001 (group S). An ultrasonic scalpel (Harmonic Scalpel; Ethicon EndoSurgery, Cincinnati, OH) was used for skeletonization and removing satellite veins and surrounding tissue. CABG was performed by the standard technique. Perioperative results were prospectively collected and compared between the two groups. Early angiographic results performed within 3 months were also compared.

RESULTS

There were two hospital deaths in group S. Major complications were observed in 11 (8.4%) in group S and 3 (2.7%) in group P (p = not significant [NS]). None were related to the radial artery graft. Angiography was obtained in 96 patients of group S and 76 patients in group P and revealed that the stenosis free graft patency rate of group S (138 of 143, 96.5%) was superior to that of group P (73 of 86, 84.9%) with p < 0.005.

CONCLUSIONS

Skeletonization of the radial artery with the ultrasonic scalpel is safe and contributes to reducing the incidence of early graft stenosis.

On-pump versus off-pump coronary artery bypass using quadruple arterial grafts

The optimal combination of arterial grafts for quadruple coronary artery bypass is the bilateral internal mammary artery, the radial artery, and the gastroepiploic artery. Patients who underwent quadruple bypass in our hospital group between December 1995 and March 2001 were retrospectively analyzed to determine whether off-pump surgery (n = 27) provides better outcomes than conventional on-pump surgery (n = 51). Preoperative risk factors as well as the mean number of distal anastomoses (4.5 in the off-pump versus 4.8 in the on-pump patients) were not significantly different between the 2 groups. Postoperative recovery was significantly faster in the off-pump group than in the on-pump group (intubation time, 6.4 versus 16 hours; stay in intensive care unit, 2 versus 3 days; and postoperative hospital stay, 12.3 versus 15.8 days). Early stenosis-free graft patency rates did not differ significantly (90.3% versus 89.3%). No late cardiac events were observed in the off-pump group, while 4 occurred in the on-pump group. Quadruple arterial bypass without cardiopulmonary bypass is safe, and it allows faster recovery. The follow-up results of off-pump patients so far have been satisfactory.

Efficacy of off-pump coronary artery bypass grafting for the patients on chronic hemodialysis

OBJECTIVE

Coronary artery bypass grafting (CABG) under a beating heart is reported to be less invasive and promise earlier recovery. This study was performed to evaluate the efficacy of off-pump CABG in patients with end-stage renal failure.

METHODS

Isolated CABG was performed on 40 hemodialysis patients at Shin-Tokyo Hospital Group between September 1, 1993, and December 31, 2000. Among them, off-pump CABG was performed in 16 and on-pump CABG in 24. Their preoperative, perioperative, and follow-up data were retrospectively collected.

RESULTS

Patient's demographics and coronary risk factors were similar in off-pump and on-pump groups. The mean number of bypass grafts was 1.9 +/- 1.1 in the off-pump group and 2.8 +/- 1.1 in the on-pump group (P < 0.05). Blood transfusion was significantly less frequent in the off-pump group than in on-pump group. Postoperative complications were more frequently observed in the on-pump group (7.1% off-pump vs 25.0% on-pump). There were two hospital deaths in the on-pump group and none in the off-pump group. Postoperative intubation time, ICU stay, and hospital stay were significantly shorter in the off-pump group than in the on-pump group. Although follow-up period was short (1.1 +/- 0.7 years), no cardiac events occurred in the off-pump group.

CONCLUSIONS

Off-pump CABG for hemodialysis patients is safe and useful and it enables early recovery. Postoperative cardiac events were controlled effectively during the short period of follow-up.

Off-pump coronary artery bypass grafting for elderly patients

BACKGROUND

The use of off-pump coronary artery bypass grafting (CABG) has recently become widespread, and it has been proven to be less invasive and to facilitate early recovery. In this study, we investigated the efficacy of off-pump CABG for patients aged 75 years or more.

METHODS

A retrospective chart review was carried out for patients who underwent isolated off-pump and on-pump CABG at Shin-Tokyo Hospital between January 1997 and December 2000. The patients' demographic, operative data, and postoperative results were collected.

RESULTS

The off-pump group consisted of 60 men and 44 women with a mean age of 78.8 years, and the on-pump group consisted of 54 men and 20 women with a mean age of 77.6 years. Distal anastomoses were significantly fewer in the off-pump group (2.4 in off-pump group versus 3.7 in on-pump group), but total arterial bypass was more frequently achieved in off-pump group (82.7% versus 25.7%). Intubation time (8.4 versus 18.4 hours), intensive care unit stay (2.2 versus 3.5 days), and postoperative stay (13.8 versus 20.0 days) were significantly shorter in the off-pump group than in the on-pump group (p < 0.05). The frequency of the occurrence of major complications was significantly lower in the off-pump group than the on-pump group, especially in regard to postoperative stroke and respiratory failure (p < 0.05). Multivariate analysis showed that off-pump CABG significantly reduced patient recovery period and the incidence of postoperative complications. Early follow-up results, cardiac event-free and survival rates, did not significantly differ between the two groups.

CONCLUSIONS

Off-pump CABG is safe for the elderly patient. Off-pump CABG successfully facilitates early recovery and reduces the incidence of postoperative complications among elderly patients.

Double-vessel revascularization using a composite graft approached from small left thoracotomy

Minimally invasive direct coronary artery bypass usually includes single vessel revascularization via a small skin incision. In most cases, the left internal mammary artery has been used for bypassing to the left anterior descending artery, and only single vessel revascularization used to be performed due to the limited operating field. We present 2 cases of successful double-vessel revascularization approached from a left small thoracotomy, using a composite graft of the internal mammary artery and the inferior epigastric artery, anastomosing to the left anterior descending artery and diagonal artery.

Coronary artery bypass grafting for octogenarians: experience in a private hospital and review of the literature

BACKGROUND AND METHODS

Indications for coronary artery bypass grafting (CABG) are expanding. We retrospectively analyzed the results of isolated CABG performed at Shin-Tokyo Hospital between January 1, 1992, and August 31, 2000. Preoperative, perioperative, and follow-up data of patients 80 years of age or older (group E, n=55) were collected and compared with those of patients between 75 and 79 years of age (group Y, n=197).

RESULTS

Patient demographics were not significantly different except there was a greater incidence of co-existing valvular disease in group E. CABG was completed without any significant differences, except fewer distal anastomoses and more frequent off-pump CABG were performed in group E than in group Y. The in-hospital mortality rates of group E and Y were 1.8% and 2.5%, respectively (p=NS). The postoperative recovery (intubation time, ICU stay, and postoperative hospital stay) of group E was similar to group Y. During the mean follow-up of 2.6 years (maximum 8.4 years), the actuarial 3-year survival of groups E and Y was 84.5% and 94.9% (p=NS), respectively, excluding in-hospital mortality. The actuarial 3-year cardiac event-free rates were 100% in group E and 88.4% in group Y (p=NS).

CONCLUSION

CABG for octogenarians can be performed safely. Once adequate revascularization was established, the long-term cardiac events were similar to those of the younger patients.

Coronary artery bypass grafting for patients with non-dialysis-dependent renal dysfunction (serum creatinine > or =2.0 mg/dl)

INTRODUCTION

Patients with renal dysfunction carry a risk of coronary atherosclerosis. The purpose of this study was to evaluate the outcome after coronary artery bypass grafting (CABG) in patients with decreased renal function (serum creatinine > or =2.0 mg/dl).

METHODS

We retrospectively analyzed consecutive patients who had undergone isolated CABG at Shin-Tokyo Hospital between May 1, 1991 and April 31, 2000. Preoperative, perioperative, and follow-up data of the non-dialysis-dependent patients with preoperative serum creatinine equal to or more than 2.0mg/dl (group R, n=59) were collected, and compared with those of the control patients (serum creatinine < 2.0, group C, n=1666). Group R was further divided into the off-pump and on-pump CABG group and their perioperative results were compared.

RESULTS

Group R included 51 males and eight females with a mean age of 66.4. The mean number of anastomoses was not significantly different between groups; however, clump time and pump time were longer in group R. Postoperative recovery was longer in group R than in group C, which is associated with a more frequent occurrence of major complications (28.8% in group R and 10.7% in group C, P<0.0001) and mortalities (6.8% in group R and 0.5% in group C, P<0.0005). The patients who underwent off-pump CABG experienced relatively faster recovery than those who underwent on-pump CABG, despite decreased renal function. At the mean follow-up of 2.4 years, the actuarial 3-year survival rate of groups R and C were 75.3 and 96.9%, respectively (P<0.0001), excluding hospital mortality. The actuarial 3-year cardiac event-free rate was 76.7% in group R and 87.3% in group C (P<0.05).

CONCLUSIONS

Patients with decreased renal function carry significant operative risks and require prolonged hospital care. Even after adequate surgical revascularization was completed, the long-term cardiac event-free and survival rates in the patients with renal dysfunction were inferior to the patients with normal renal function.

Coronary artery bypass grafting using the radial artery: midterm results in a Japanese institute

BACKGROUND

To avoid remote cardiac events associated with graft occlusions, arterial conduits are being increasingly utilized in coronary artery bypass grafting (CABG). The development of antispasmic agents has enabled the use of the radial artery as a graft conduit in CABG.

METHODS

Between December 1995 and December 1998, 920 consecutive isolated CABG operations were performed at Shin-Tokyo Hospital. The radial artery was used for graft conduits in 475 of these patients, and their data were analyzed in this study. The patients were followed to determine midterm graft patency, cardiac events, and survival. All data are given as mean +/- standard deviation. The end points were patient death or occurrence of cardiac events.

RESULTS

The radial artery was used in 475 patients (366 males and 109 females, with a mean age of 64.5+/-8.5 years). The left internal mammary artery was used in 94.9% of patients, the right internal mammary artery in 17.5%, the gastroepiploic artery in 50.9%, the inferior epigastric artery in 0.2%, and the saphenous vein in 39.2%. The in-hospital morbidity and mortality rates of the studied group were 12.8% and 0.6%, respectively. A major complication related to radial artery harvesting, compartment syndrome of the arm due to postoperative bleeding, was observed in 1 patient. No postoperative myocardial infarction attributable to radial artery bypass was observed. During the late follow-up period of 3.5+/-0.9 years, cardiac events were observed in 63 patients, giving actuarial 2- and 3-year event-free rates of 92.8% and 89.6%, respectively. A total of 24 late deaths were noted, including seven cardiac deaths, giving actuarial 2- and 3-year survival rates of 98.1% and 97.2%, respectively. Postoperative angiography was performed in selected patients. The cumulative graft patency rate of the radial artery was 93.0% during the mean angiographical follow-up period of 1.5+/-1.1 years.

CONCLUSIONS

No adverse effects were noted after CABG using a radial artery graft in this short- and midterm follow-up period.

A previous mastectomy does not increase sternal complications after coronary artery bypass grafting regardless of whether an internal mammary artery is used

A mastectomy for breast cancer may alter the selection of grafts or the postoperative outcomes after coronary artery bypass grafting (CABG). To clarify these points, a retrospective analysis of patients who underwent CABG after a mastectomy was undertaken. A total of 19 mastectomy patients (13 left, 6 right, and 1 bilateral mastectomy) were identified prior to CABG, and their perioperative data as well as late outcomes were examined. The studied group consisted of all females with a mean age of 68.8 +/- 6.2 years. The internal mammary artery (IMA) was used in 14 (73.7%) patients; however, there were no patients in whom bilateral IMAs were harvested. Among these 14 patients, an ipsilateral IMA was harvested in 6 and a contralateral IMA in 8. Alternative grafts were selected in 6 patients. A contralateral IMA or other graft conduits were utilized instead of an ipsilateral IMA. There were no in-hospital deaths or sternal wound complications. With a mean follow-up of 2.6 years, 3 patients died (1 cardiac death and 2 noncardiac deaths) and 1 patient developed angina due to de-novo coronary artery stenosis. In patients who have undergone a previous mastectomy, CABG using a single IMA is considered to be safe. If the IMA has good pulsation and if IMA harvesting is not difficult, even after a mastectomy, it can be used as a graft conduit without increasing the risk of sternal wound complications.

Specific antibodies to Porphyromonas gingivalis Lys-gingipain by DNA vaccination inhibit bacterial binding to hemoglobin and protect mice from infection

Lys-gingipain (KGP), a lysine-specific cysteine proteinase, is one of the major virulence factors of Porphyromonas gingivalis. Here we examined the involvement of the catalytic domain of KGP (KGP(cd)) in hemoglobin binding by P. gingivalis, using a specific immunoglobulin G (IgG) elicited by the administration of plasmid DNA encoding KGP(cd) or the catalytic domain of Arg-gingipain (RGP(cd)). The pSeq2A/kgp(cd) and pSeq2B/rgp(cd) plasmids were constructed by the ligation of kgp(cd) and rgp(cd) DNA fragments, respectively. Female BALB/c mice were immunized with each of these plasmids. pSeq2A/kgp(cd) elicited a strong response to recombinant KGP(cd) (rKGP(cd)), as well as to comparably produced rRGP(cd)-reactive antibodies. The serum antibodies elicited by pSecTag2B/rgp(cd) also cross-reacted with rKGP(cd) as well as rRGP(cd). Anti-KGP(cd) IgG significantly inhibited hemoglobin binding by P. gingivalis. Furthermore, the inhibition of hemoglobin binding was markedly enhanced by a combination of anti-KGP(cd) and anti-fimbriae. Anti-RGP(cd) IgG showed a negligible inhibitory effect, while both anti-KGP(cd) and anti-RGP(cd) IgGs showed significant inhibitory effects on Lys- and Arg-specific proteolytic activities and on the growth of P. gingivalis under iron-restricted conditions where supplemented hemoglobin was the sole iron source. Immunized mice were challenged by intraperitoneal inoculation with P. gingivalis. All nonimmunized mice died within 72 h; however, vaccination with pSeq2A/kgp(cd) and pSeq2B/rgp(cd) prevented inflammatory responses and prolonged the survival rate of immunized mice by 43 and 27%, respectively. These results suggest that KGP(cd) acts as a hemoglobin-binding protein and can also be useful as an immunogen inducing a protective response to P. gingivalis infection.

[New subjects for exceeding conventional on-pump CABG]

Coronary artery bypass grafting (CABG) used to be performed under cardiac arrest and cardiopulmonary bypass (CPB). During the last decade, efforts were made to minimize CPB-related complications. The technique of off-pump CABG (OPCAB) has been established during the last 5 years. Elimination of CPB and OPCAB has successfully reduced a number of perioperative complications and has provided early patient recovery. A compression type of coronary stabilizer was used early phase of OPCAB. Off-pump revascularization using the compression device was limited to the anterior wall of the heart. Bypass to the posterior wall under a beating heart was not popular until the suction type of stabilizer had become available. A suction device assisted by the Lima's pericardial suture allowed us to perform bypass grafting any aspects of the heart. Recently, we are skeltonizing the arterial grafts using the Harmonic scalpel. Applying skeltonizing technique to the radial artery or internal thoracic artery, we can successfully perform sequential grafting in selected cases. The number of distal anastomoses has been gradually increased as the device and technique were advanced (2.1 distal anastomoses with a compression device, 2.9 with a suction device, and 3.2 with the skeltonization technique). The frequency of the complete revascularization also increased. On the other hand, the complications associated with the procedure were comparable among these three off-pump methods, but were significantly fewer than on-pump CABG. Currently performed OPCAB can provide almost same number of distal anastomoses as on-pump CABG, with less frequency of postoperative mortality and morbidity, and with early patient recovery. These favorable results were attributed to the progress of the device and technique.

Coronary artery bypass grafting for hemodialysis-dependent patients

Patients with end-stage renal disease carry a risk of coronary atherosclerosis. This study was performed to evaluate the perioperative and remote data of coronary artery bypass grafting (CABG) in hemodialysis dependent patients. We retrospectively analyzed the results of isolated CABG performed at Shin-Tokyo Hospital between June 1, 1993 and May 31, 2000. Preoperative, perioperative, and follow-up data of the patients on hemodialysis (Group HD, n = 37) were collected and compared with those of control patients (Group C, n = 1,639). Group HD consisted of 26 males and 11 females with a mean age of 59.9 +/- 8.1 years, and the mean number of bypasses was 2.5 +/- 1.1. Group HD had a longer postoperative intubation time, ICU stay, and hospital stay than Group C. The postoperative major complication rate in Group HD (18.9%) was not significantly different from that in Group C (11.3%). However, the inhospital mortality rate in Group HD (5.4%) was higher than Group C (0.6%). At the mean follow-up of 2.4 years, the actuarial 3-year survival of Groups HD and C were 90.6% and 97.6%, respectively (p < 0.001), excluding hospital mortality. The actuarial 3-year cardiac event-free rates were 84.3% in Group HD and 88.8% in Group C, showing no difference. Patients on chronic hemodialysis carry a significant risk of prolonged inhospital care and hospital death. Once successful surgical revascularization was completed, their long-term cardiac events could be controlled as effectively. The increased distant death rates was probably associated with the nature of renal disease.

Altered antigenicity in periodontitis patients and decreased adhesion of Porphyromonas gingivalis by environmental temperature stress

Periodontopathogenic bacteria survive various environmental changes during the progression of periodontal disease. Alterations in metabolism and protein expression will have to take place to adapt their physiological functions to environmental stress. We examined the effects of an elevation of 2 degrees C in temperature on the adhesive ability and antigenicity of Porphyromonas gingivalis. Elevation of growth temperature of P. gingivalis from 37 degrees C to 39 degrees C remarkably suppressed the expression of surface filamentous structures, such as fimbriae, as well as the adhesive capacities to salivary components and Streptococcus oralis. Sera of severe periodontitis patients revealed a marked increase in serological activity with 39 degrees C cells than with 37 degrees C cells. The alteration of protein profiles of bacterial surface components by temperature elevation was demonstrated by SDS-PAGE, and their Western blot profiles were also different from those of cells grown at 37 degrees C. Although a uniform trend was not found in the altered patterns, sera from severe periodontitis patients detected more antigenic proteins in cells grown at 39 degrees C than 37 degrees C cells. These observations suggest that P. gingivalis downregulates the expression of fimbriae and alters its adhesive capacity and antigenicity by the temperature stress that could occur during the disease progression.

Relationship of periodontopathic bacteria with early-onset periodontitis in Down's syndrome

BACKGROUND

Down's syndrome (DS) patients often develop severe early-onset marginal periodontitis in early adulthood; however, there is little information available on the microbiology of DS periodontitis.

METHODS

Subgingival plaque specimens were taken from 67 DS young adults and 41 age-matched systemically healthy individuals with mental disabilities (MD). The prevalence of 10 possible periodontopathic bacterial species, Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Bacteroides forsythus, Treponema denticola, Prevotella intermedia, Prevotella nigrescens, Capnocytophaga ochracea, Capnocytophaga sputigena, Campylobacter rectus, and Eikenella corrodens, were investigated in their subgingival plaque samples using a polymerase chain reaction method. The detection of P. gingivalis fimA genotypes was also performed in P. gingivalis-positive samples.

RESULTS

Although DS subjects generally develop an earlier and more extensive periodontal breakdown than those with MD, no significant differences were observed in the bacterial profiles. The profiles of subjects with periodontitis were significant in DS, but not in MD. The prevalence of P. gingivalis, B. forsythus, and P. intermedia were significant in the DS periodontitis group, compared to DS gingivitis group. Moreover, the occurrence of P. gingivalis with the type II fimA gene was significantly related to periodontitis in both DS and MD, with odds ratios of 6.32 and 12.03, respectively.

CONCLUSIONS

These results suggest that early-onset periodontitis in DS is mainly due to the more susceptible host for the causative microbial agents including P. gingivalis with type II fimA.

Amlodipine-induced gingival overgrowth: periodontal responses to stopping and restarting the drug

A case history of a woman with gingival overgrowth (GO) induced by amlodipine is presented. A 49-year-old Japanese woman, who was taking amlodipine, had gingival overgrowth and swelling on examination. No specific periodontal treatment was provided to the patient for the GO; however, the amlodipine was replaced with an ACE inhibitor after consultation with her medical practitioner. Within two months, the suspension of amlodipine resulted in a significant improvement in her periodontal condition. Failure to control the hypertension caused the physician to re-prescribe amlodipine. After three months, the gingival overgrowth returned; however, its severity was less when compared with the original periodontal condition, due to reduction in drug dose and periodontal therapy. This experience suggests that temporary suspension of a drug which can induce GO can improve the periodontal condition without the aid of surgical treatment.

Complicated Cardiac Surgery in Renal Transplant Patient

Concomitant mitral valve repair, maze procedure, and coronary artery bypass grafting were carried out in a renal transplant recipient. The operation was complicated by intraoperative iatrogenic ascending aortic dissection that was successfully repaired.

[Anesthetic management of a patient with pheochromocytoma and cerebral ischemic attacks]

A 15-year-old girl with history of two cerebral ischemic attacks possibly caused by cerebral vascular spasm was diagnosed as having a pheochromocytoma, and was scheduled for laparoscopic removal of the adrenal tumor. Epidural catheterization was performed at Th 12/L 1. General anesthesia was induced with thiamylal and vecuronium, and maintained with nitrous oxide-oxygen-isoflurane and continuous epidural infusion of 1.5% lidocaine. Phentolamine and thiamylal were continuously administrated into the vein. While operating on the tumor, abnormal hypertension did not occur. Just after removal of the tumor, the systolic blood pressure fell to 50-70 mmHg. The hypotension continued for about 75 min, despite administration of dopamine, norepinephrine and epinephrine. After the emergence from anesthesia, the blood pressure recovered to normal level. No neurocerebral abnormality was found. In patients like this one, we have to prevent cerebral vascular spasm and cerebral infarction caused by excessive secretion of catecholamines.

Off-pump coronary artery bypass. Mid-term results

OBJECTIVES

Off-pump coronary artery bypass grafting (CABG) on the beating heart has become popular procedure in cardiac surgery and its initial results appeared favorable. We report our early and mid-term results of off-pump CABG performed at Shin-Tokyo Hospital.

METHODS

Medical records of patients undergoing off-pump or conventional on-pump CABG from September 1, 1996, to August 31, 1999 were retrospectively reviewed. Patients underwent off-pump CABG were further classified into 2 groups; MIDCAB (Off-pump CABG for single vessel revascularization via a small skin incision) and OPCAB (off-pump CABG mainly approached via midline sternotomy) group. Their preoperative, perioperative, and follow-up data were collected and analyzed.

RESULTS

Among a total of 995 cases of CABG, 194 cases were off-pump CABG (male/female 142/52, mean age 66.9). The mean number of distal anastomoses in off-pump CABG was 1.9 +/- 0.9 (1.0 +/- 0.0 in MIDCAB and 2.3 +/- 0.7 in OPCAB), which was significantly fewer than in on-pump CABG (3.6 +/- 1.1), with p < 0.0001. Intubation time (5.3 +/- 5.7 hours in off-pump CABG vs 13.1 +/- 24.2 hours in on-pump CABG), ICU stay (1.7 +/- 1.1 vs 3.2 +/- 3.0 days), and postoperative hospital stay (14.0 +/- 7.9 vs 18.1 +/- 12.1 days) in off-pump CABG were significantly shorter than in on-pump CABG (p < 0.0001). In the off-pump CABG group, there were no in-hospital deaths and 14 major complications, fewer than in on-pump CABG (8 hospital deaths and 114 major complications). Postoperative angiography before hospital discharge was conducted in 80 patients (41.2%) and showed 2 occlusions, giving a graft patency rate of 98.6% in the off-pump group. During follow-up (0.9 +/- 0.6 year) period, there were 5 non-cardiac deaths and 20 cardiac events in the off-pump group. The actuarial survival rate at 36 months was 94.6% for off-pump CABG, showing no significant difference from the rate for conventional CABG patients (95.2% at 36 month, p = NS) The event-free rate was 84.0% at 36 months in off-pump CABG patients; however, which was less favorable than on-pump CABG patients (88.0% at 36 months, p < 0.05).

CONCLUSIONS

Both in-hospital and mid-term results for off-pump CABG patients were acceptable. Isolated CABG can thus be safely performed without cardiopulmonary bypass. Advances in coronary stabilization have contributed to these improved results. The observed long-term cardiac events may be related to incomplete revascularization.