Percutaneous coronary intervention on combined VA-ECMO and IMPELLA (ECPELLA) support may reduce myocardial damage in cardiogenic shock patients with STEMI who required mechanical circulatory support

Background

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an effective therapeutic modality for patients with cardiogenic shock (CS) including STEMI. The VA-ECMO maintains end-organ perfusion, however, it significantly increases damaged left ventricular (LV) afterload. Combined treatment of VA-ECMO and a micro-axial Impella pump, ECPELLA, simultaneously provides systemic circulatory support and LV loading reduction (LV unloading). Studies in ischemic animal models displayed that LV unloading reduced myocardial size. However, it remains unknown whether LV unloading effect by ECPELLA during percutaneous coronary intervention (PCI) can reduce myocardial damage in human STEMI patients with severe cardiogenic shock.

Purpose

This study was to assess whether PCI on ECPELLA support can reduce myocardial damage in STEMI patients with severe cardiogenic shock.

Methods

Sixteen consecutive patients with STEMI and lethal CS (SCAI stage E) were enrolled. All patients suffered from cardiac arrest. Fifteen patients (94%) underwent extracorporeal cardiopulmonary resuscitation using VA-ECMO. From October 2018 to November 2019, PCI was carried out on VA-ECMO support and the mechanical circulatory support (MCS) modality during PCI was switched to ECPELLA since December 2019. There were 8 patients who underwent PCI on ECPELLA support (ECPELLA-PCI) and 8 patients who underwent PCI on single VA-ECMO support (ECMO-PCI). All patients in ECMO-PCI group were escalated to ECPELLA after PCI. Therefore, the difference between groups was timing of LV unloading, i.e., pre-PCI or post-PCI condition. We assessed total MCS flow during PCI, and peak and time course changes in CK-MB levels from days 0 to 3.

Results

There were no significant differences in age, rate of male sex, body surface area, shockable rhythm, serum lactate levels, and door to MCS time. Patients in ECPELLA-PCI had significantly longer door to recanalization time (73min in ECPELLA vs. 49min in VA-ECMO, p<0.05), and higher total MCS flow during PCI (3.1 L/min/sqM vs. 2.0 L/min/sqM, p<0.05). Peak and the area under the curves (AUC) from day 0 to day 3 of CK-MB in ECPELLA-PCI were significantly lower than ECMO-PCI group (peak CK-MB 120 vs. 524 IU/L and CK-MB AUC 143 vs. 464 IU/L*Day, respectively, p<0.05). While all patients received red blood cell (RBC) and plasma (PL) transfusions, ECPELLA-PCI required larger amount of RBC and PL transfusions (p<0.05).

Conclusion

The ECPELLA-PCI appeared to reduce myocardial damage shown by peak and AUC of CK-MB levels. Lager amount of blood transfusion is a major drawback of this treatment modality. Further studies are necessary whether ECPELLA-PCI is an effective revascularization approach for myocardial damage reduction with favorable mid- and long-term outcome in patients with STEMI with severe cardiogenic shock.

Funding Acknowledgement

Type of funding sources: None. Total MCS FLow and Ttoal MCS flow indexPeak CK-MB and CK-MB AUC

Combined use of VA-ECMO and IMPELLA (ECPELLA) as a possible strategy to improve outcomes in patients who underwent E-CPR

Background

Extracorporeal Cardio-Pulmonary Resuscitation (E-CPR) is an effective tool for patients with refractory cardiac arrest (CA). Since VA-ECMO provides strong afterload, IABP is often used to increase left ventricular load. Recently, in Japan, the effectiveness of VA-ECMO in combination with IMPELLA, a forward flow mechanical circulatory support device (ECPELLA) is gaining attention.

Purpose

We investigated usefulness of ECPELLA in patients with refractory CA.

Method

We reviewed 133 patients that had E-CPR from January 2012 through January 2020 {mean age: 67±15 years, male 65%, Out of hospital Cardiac Arrest (OHCA) 35%, Acute coronary Syndrome (ACS) 54%}. We divided these patients into ECMO with IMPELLA (ECPELLA group), ECMO with IABP (IABP group) and ECMO alone (ECMO alone group). The primary endpoint is 30-day survival and good neurological prognosis defined as CPC (cerebral performance categories) 1 or 2.

Result

During the study period, of the 133 patients, there were 20 in the ECPELLA group, 78 in the IABP group, 35 in the ECMO alone group. There were no significant differences in age in all three groups. There were more males, shockable rhythm, OHCA and ACS in the ECPELLA and IABP groups compared to the ECMO alone group. But there was no significant difference between the ECPELLA and IABP groups. Compared with other groups, ECPELLA had the shortest time from cardiac arrest to ECMO placement. Regarding endpoints, the rate of 30-day survival and favorable neurological prognosis were higher in the ECPELLA group, followed by the IABP group and then the ECMO alone group. (ECPELLA: 55% vs. IABP: 23% vs. ECMO alone: 9%; P=0.0009, ECPELLA: 35% vs. IABP: 13% vs. ECMO alone: 9%; P=0.04) Next, Kaplan Meier analysis was performed to analyze 30-day all-cause mortality. The ECPELLA group had a significantly higher survival rate (P=0.01 by log-rank test). Multivariate cox proportional hazard analysis including the age, OHCA, shockable rhythm, ACS, Collapse-to-ECMO under 60 min revealed that the age (hazard ratio [HR], 1.28 (10 years increase), 95% confidence interval [CI], 1.08–1.53, P=0.004) and Collapse-to-ECMO under 60 min (HR, 0.37, 95% CI, 0.21–0.68, P=0.001) or ECPELLA (HR, 0.46, 95% CI, 0.20–0.694, P=0.03) were significantly associated with mortality.

Conclusion

ECPELLA used with E-CPR is an effective tool to improve mortality and neurologic status.

Funding Acknowledgement

Type of funding source: None

Occurrence of parasympathetic vasodilator fibers in the lower lip of the guinea-pig

The present study was designed to examine whether there are parasympathetic vasodilator fibers in the lower lip of the guinea-pig. Electrical stimulation of the central cut end of the lingual nerve of guinea-pigs evoked intensity- and frequency-dependent decreases in lower lip blood flow and systemic arterial blood pressure (SABP). Pretreatment with guanethidine, a postganglionic sympathetic nerve blocker and antihypertensive drug (30 mg kg(-1), s.c., 24 h prior to experiments), reduced the magnitude of the decrease in SABP while the intensity- and frequency-dependent increases of the lip blood flow occurred by the lingual nerve stimulation only on the side ipsilateral to stimulation. Increases in the lip blood flow evoked by lingual nerve stimulation in guanethidine pretreated guinea-pigs were reduced by hexamethonium (an autonomic ganglion cholinergic blocker) in a dose-dependent manner. When fluoro-gold (a retrograde neural tracer) was injected into the lower lip, labeled neurons were observed in the ipsilateral otic ganglion. The present study indicates the presence of parasympathetic vasodilator fibers originating from the otic parasympathetic ganglion in the guinea-pig lower lip, similar to those reported previously in rats, cats, rabbits and humans.

Comparison between in vivo and in vitro pharmacokinetics of succinylcholine in humans

PURPOSE

To compare the in vivo and in vitro pharmacokinetics of succinylcholine (SCh) in humans.

METHODS

A bolus of SCh 1 mg.kg(-1) (n = 7) or 2 mg.kg(-1) (n = 11) was given to 18 patients anesthetized with thiopental. Arterial blood samples for determination of in vivo SCh concentrations were collected every 30 s for 5 min. Another 20-ml blood sample was obtained before induction of anesthesia for determination of in vitro SCh. Concentrations of SCh were measured by high-performance liquid chromatography. In vivo and in vitro concentrations of SCh vs time data were analyzed by the one-compartment model.

RESULTS

The respective in vivo and in vitro pharmacokinetic parameters (SCh 1 mg.kg(-1) vs SCh 2 mg.kg(-1)) were as follows: Plasma clearance was 4.17 +/- 2.37 and 1.85 +/- 0.28 l.min(-1), P < 0.05, vs 2.91 +/- 2.01 and 1.27 +/- 0.43 l.min(-1), P < 0.05. Elimination half-life was 25.4 +/- 10.6 and 47.4 +/- 5.4 s, P < 0.002 vs 26.3 +/- 10.0 and 75.2 +/- 21.8 s, P < 0.00005.

CONCLUSION

These results suggest that the rapid disappearance of SCh from the circulation is due to diffusion out of the blood vessels rather than to enzymatic hydrolysis.

Unusual presentations of spilled gallstones

Perforation of the gallbladder with resultant spillage of gallstones is not an uncommon occurrence. Spillage is reported to occur in 6% to 40% of laparoscopic cholecystectomies. Although not generally considered a significant problem, retained gallstones may cause serious complications years after the operation, with a clinical presentation that often is confusing. We report two cases of unusual complications from spilled gallstones. The first patient presented with clinical and radiologic findings of acute appendicitis 8 years after the laparoscopic cholecystectomy. The second patient presented with spontaneous erosion of spilled gallstones through the back 2 years and 9 months after the laparoscopic cholecystectomy. The literature is reviewed, and the management of spilled gallstones is discussed briefly. Although the complication rate is low, every effort should be made to retrieve spilled gallstones, and the event should be recorded in detail in the operative record. Obligatory conversion to an open procedure is not necessary.

delta15N of seagrass leaves for monitoring anthropogenic nutrient increases in coral reef ecosystems

In a coral reef environment, a slight increase in dissolved inorganic nitrogen (DIN;> or =1.0 micro M) can alter the ecosystem via macroalgal blooms. We collected seagrass leaves from the tropical and subtropical Pacific Ocean in five countries and examined the interactions between nutrient concentrations (C, N, P), molar ratios of nutrients, and delta15N to find a possible indicator of the DIN conditions. Within most sites, the concentrations of nutrients and their molar ratios showed large variations owing to species-specific values. On the other hand, almost identical delta15N values were found in seagrass leaves of several species at each site. The correlations between delta15N and nutrient concentrations and between delta15N and molar ratios of nutrients suggested that nutrient availability did not affect the delta15N value of seagrass leaves by altering the physiological condition of the plants. Increases in delta15N of seagrass leaves mostly matched increases in DIN concentrations in the bottom water. We suggest that delta15N in seagrass leaves can be a good tool to monitor time-integrated decrease/increase of DIN concentrations at a site, both in the water column and the interstitial water.

Comparison of the responses of global tests of coagulation with molecular markers of neutrophil, endothelial, and hemostatic system perturbation in the baboon model of E. colisepsis--toward a distinction between uncompensated overt DIC and compensated non-overt DIC

This study correlates changes in neutrophilic activity and endothelial injury with markers of hemostatic activity following the infusion of increasing concentrations of E. coli organisms. It focuses on the hemostatic response as a marker of microvascular injury and uses the response to increasing concentrations of E. coli to refine our definition of disseminated intravascular coagulation (DIC) and distinguish between a compensated (non-overt DIC) and uncompensated (overt DIC) response. We observed that the global coagulation tests reflected activation of the hemostatic system in a dose dependent manner (overt DIC) in the early phases (T+2 to 6 h) of the response to increasing concentrations of E. coli, but that they failed to do so in the late phases (T+ 24 to 48 h). We observed that molecular markers, soluble thrombomodulin and elastase, unlike thrombin/antithrombin and plasmin/antiplasmin complexes, remained elevated out to T+24 to 48 h indicating endothelial injury that persists beyond the initial inflammatory insult in compensated as well as uncompensated DIC.

[Strong opioids]

Oral route morphine should be first choice for moderate or strong cancer pain. Morphine must be administered essentially at fixed interval. It is important to keep effective plasma morphine concentration. When a patient can not take morphine via oral route, morphine must be administered by intravenous or subcutaneous infusion. Respiratory rate per minute of patients always must be measured during administration of morphine. Patients taking morphine have to take laxatives and antiemetics simultaneously. It is crucial to establish the cause of pain and choose other proper treatment when morphine is not effective.

Identifying sources and mass balance of dioxin pollution in Lake Shinji Basin, Japan

On the basis of congener-specific analysis of dioxins in a dated sediment core, the sources and behavior of dioxins in Lake Shinji Basin, Japan, were estimated. The dioxins in the core showed that their deposition in the lake increased rapidly during the 1960s, peaked in the early 1970s, and then decreased gradually. Principal component analysis of the congener-specific data showed that three major sources existed: pentachlorophenol (PCP), chloronitrophen (CNP), and combustion. PCP and CNP are paddy field herbicides used extensively in the basin. The time trends of source contributions were estimated by multiple regression analysis using the source profiles. The results revealed that dioxin emission from PCP and CNP herbicides was high in the 1960s and the early 1970s, respectively. The contributions from PCP, CNP, and combustion in recent surface sediment were about 68, 16, and 16% in terms of total amount of dioxins. From the decreasing trend of dioxin deposition in the lake after extensive herbicide use, the amount of dioxins that accumulated in the agricultural soil in the basin was estimated to have decreased by about 2%/yr or a half-life of about 35 yr, indicating that dioxin runoff from agricultural fields would continue for a long time.

[Giant epidermal cyst in the perineum extending into the pelvic space in the patient with polycystic kidney disease: a case report]

A 75-year-old man with autosomal dominant polycystic kidney disease was admitted to our hospital with the chief complaint of a giant mass in the left side of the perineum that had gradually developed in size during the previous 20 years. Palpation revealed a neonatal head-sized cystic mass with no tenderness. Magnetic resonance imaging (MRI) demonstrated a well-circumscribed homogeneous mass extended to the dorsal side of the bladder. It was excised surgically without any injury of rectum or urinary tract. The resected specimen was 23 x 18 x 12 cm in size and 1.2 kg in weight. The pathological diagnosis was epidermal cyst. Cases with an epidermal cyst extending into the pelvic space are extremely rare with few cases having been reported in the world.

Power spectral analysis of the electroencephalogram during induced total spinal block

PURPOSE

To evaluate the effects of total spinal block (TSB) on brain function, TSB-induced changes in cortical electrical activities were analyzed using power spectral analysis of an electroencephalogram (EEG).

METHODS

Six patients suffering from chronic pain who were undergoing TSB therapy were studied. TSB was established with intrathecal 1% lidocaine (0.3 ml.kg(-1)) injected through the C1-2 lateral intervertebral space. Mechanical ventilation was continued via a laryngeal mask until the recovery of respiration. The EEG recording was started before TSB induction and continued until 10 min after extubation. The following processed EEG parameters were monitored: spectral edge frequency-90% (SEF90), spectral median frequency (SMF), and relative power in the frequency bands of delta, theta, alpha, beta, and the delta ratio [(alpha + beta)/delta].

RESULTS

TSB induced an unconscious state more than 40 min in all patients. During TSB, 12-13 Hz in SEF90 and 6-7 Hz in SMF were observed. These values are consistent with the previously reported prearousal threshold from general anesthesia. The other EEG descriptors did not change during the TSB-induced unconscious state.

CONCLUSION

The dissociation of cortical electrical activities and the clinical coma-like condition may be characteristic of the TSB-induced unconscious state.

Hepatic portal venous gas: report of a case

Hepatic portal venous gas is easily diagnosed radiographically by the appearance of tubular lucencies branching horizontally from the porta hepatis and extending to within 2cm of the liver capsule. Associated conditions vary from benign to potentially lethal diseases which require emergency operations. A case of hepatic portal venous gas secondary to small bowel obstruction is presented and a review of the literature is also provided.

Celiac plexus block in cancer pain management

The neurolytic celiac plexus block (NCPB) has been recommended for pain relief in patients with upper abdominal cancer by the WHO Cancer Pain Relief Program. In this article, we review the indications, techniques, and adverse effects of NCPB based on the previous findings in the literature and our own experience of 142 NCPBs during the past 11 years. No well-validated indication criteria for the NCPB have been available from invasive trials or non-invasive pain evaluations. Thus, the procedure has been employed using comprehensive pain assessment. Several modified approaches have been described for NCPB with differences in the target space where the alcohol is injected (precrural and retrocrural) and the insertion route of the needle (posterolateral and transdiscal). We have used the retrocrural transdiscal approach because of its simplicity and safety. The efficacy of the resultant pain relief does not differ among these techniques. Therefore, whether a distinction exists between blocks of the celiac plexus and those of the splanchnic nerves is controversial. The term "peri-aortic nerve block" may better describe the feature of this neurolytic intervention. The noteworthy adverse effects of alcoholic neurolysis include regional pain, hypotension, diarrhea, hypoxemia, and acute alcoholic intoxication. Most of them are transient and controllable. The diarrhea may counteract the morphine-induced constipation. NCPB relieves visceral pain in upper abdominal cancer with no serious adverse effects. We recommend this procedure to improve the quality of life of the patients suffering from abdominal cancer pain.

Hemostatic abnormalities in patients with thrombotic complications on maintenance hemodialysis

Before hemodialysis (HD), plasma levels of tissue factor (TF), free-TF pathway inhibitor (TFPI) and thrombomodulin (TM) were significantly higher in patients with HD than in healthy volunteers. Plasma levels of (T-F) TFPI and plasmin plasmin inhibitor complex (PPIC) were significantly higher in patients with HD than in healthy volunteers. During HD, plasma levels of TF and (T-F) TFPI were not significantly increased, but plasma levels of total TFPI and free TFPI at 1 hour after and at the end of HD were significantly increased, compared with levels before start of HD. Plasma level of PPIC 1 hour after start of HD was significantly higher than before start of HD, and plasma levels of thrombin antithrombin complex (TAT), PPIC, D-dimer, TM, and protein C (PC) at the end of HD were significantly higher than before start of HD. In patients with thrombosis complications, plasma TF levels were significantly higher than in patients without thrombotic complications during HD. Plasma levels of PC were significantly lower in patients with thrombotic complications than in patients without thrombotic complications. There was no significant difference between both groups during HD in hemostatic parameters, with the exception of TF and PC. Hemostatic abnormalities existed in patients with HD; especially, increased TF and decreased PC might cause thrombotic complications.

Risk factors and outcomes after coronary reoperation in 739 elderly patients

BACKGROUND

As second coronary artery bypass graft (CABG) operations are becoming more common in elderly patients, we conducted a retrospective analysis of risk factors for in-hospital and late outcome in patients aged 70 and over.

METHODS

We reviewed records of 739 patients who underwent second CABG at age 70 or older at our institution between 1983 and 1993. Preoperative, operative, and postoperative variables were analyzed to identify predictors of in-hospital and long-term mortality.

RESULTS

The mean age (+/- standard deviation) at reoperation was 74 +/- 3 years and the mean interval after primary operation was 130 +/- 55 months. In-hospital mortality was 7.6% (n = 56). Preoperative factors associated with increased in-hospital mortality were preoperative creatinine greater than 1.6 mg/dL (p < 0.001), emergency operation (p < 0.001), female sex (p = 0.012), moderate or severe left ventricular dysfunction (p = 0.049), and left main coronary disease (p = 0.045). In-hospital, actuarial survival was 75% at 5 years and 49% at 10 years. Cardiac event-free survival was 60% at 5 years and 27% at 10 years. The factors independently associated with increased late death were hematocrit (p = 0.046), diabetes (p = 0.011), peripheral vascular disease (p < 0.001), left ventricular function (p < 0.001), history of cancer (p = 0.016), preoperative nonsinus rhythm (p = 0.003), anticoagulation or antiplatelet therapy (p = 0.018), postoperative encephalopathy (p = 0.001), and postoperative stroke (p = 0.014).

CONCLUSIONS

CABG reoperation can have excellent results for many elderly patients, but mortality is markedly higher when elderly patients have certain risk factors and comorbidities, alone or in combination. This information should be helpful in educating patients before they decide whether to choose reoperation.

Changes of plasma hemostatic markers during percutaneous transluminal coronary angioplasty in patients with chronic coronary artery disease

Changes of hemostatic parameters during percutaneous transluminal coronary angioplasty (PTCA) in 75 patients with chronic coronary artery disease were evaluated. Plasma levels of D-dimer, soluble fibrin monomer, plasmin-alpha2 antiplasmin inhibitor complex, and tissue factor (TF) were significantly increased in all patients with chronic coronary artery disease. The activity of antithrombin and protein C and the levels of protein C antigen were significantly decreased 1 hr after PTCA, but they returned to normal range 1 day after PTCA. There was no significant difference in the level of plasma APC-PCI complex before and 1 hr after PTCA. The plasma levels of D-dimer, soluble fibrin monomer, thrombomodulin, TF and PPIC were significantly decreased 1 hr, and the plasma levels of plasmin-alpha2 antiplasmin inhibitor complex 1 day after PTCA. These findings suggest that the decrease of protein C and antithrombin resulted in activation of the coagulation system. One hour after PTCA, the plasma levels of (total-free) TF pathway inhibitor (TFPI) were significantly decreased, but the plasma levels of total and free-TFPI were significantly increased, suggesting that consumption of (total-free) TFPI occurs during PTCA. Overall, these findings suggest that the hypercoagulable state improves during PTCA and that transient decrease of antithrombin, protein C, (total-free) TFPI or plasmin-alpha2 antiplasmin inhibitor complex may cause restenosis of coronary artery.

Changes in plasma tissue factor pathway inhibitor levels during the clinical course of disseminated intravascular coagulation

In healthy volunteers, the plasma total tissue factor pathway inhibitor (TFPI) level was 68.7+/-14.1 ng/ml; the plasma free TFPI level, 17.7+/-5.4 ng/ml; the lipoprotein-associated TFPI (LP-TFPI), 51.1+/-12.0 ng/ml; the free TFPI/total TFPI ratio 0.26+/-0.07; and the plasma tissue factor levels were 149+/-46 pg/ml. Plasma tissue factor levels in patients with disseminated intravascular coagulation (DIC) were significantly higher than those in pre-DIC patients or in non-DIC patients. Plasma total-TFPI, free-TFPI and LP-TFPI levels were significantly higher in DIC patients than those in pre-DIC patients or in non-DIC patients. Before the onset of DIC, the plasma levels of tissue factor gradually increased, and 3 days before the onset of DIC they were significantly higher than those in non-DIC patients. The plasma levels of tissue factor reached their highest level 1 day before the onset of DIC and gradually decreased after the onset of DIC. Plasma levels of total-TFPI, free-TFPI, and LP-TFPI gradually increased before the onset of DIC, and the total-TFPI and LP-TFPI reached their highest levels at the onset of DIC. Plasma free-TFPI reached highest level one day after the onset of DIC. During the clinical course of DIC, the plasma level of tissue factor was the first to increase, then that of LP-TFPI and finally the free-TFPI plasma levels. These differences in the peak plasma levels of tissue factor, free-TFPI, and LP-TFPI might be related to the clinical course of DIC.

Three-dimensional anisotropy contrast (3DAC) magnetic resonance imaging of the human brain: application to assess Wallerian degeneration

Three-dimensional anisotropy contrast (3DAC) magnetic resonance imaging is a new algorithm for the treatment of apparent diffusion tensor using the three primary colors. To determine if 3DAC has a clinical application for human brain, six normal volunteers and twenty patients with supratentorial cerebrovascular accidents were examined using clinical magnetic resonance imaging (MRI), and the changes in the 3DAC images associated with Wallerian degeneration of the pyramidal tract were evaluated. The 3DAC images exhibited impressive anatomical resolution. In all chronic stage patients with hemiparesis, the colors in the pyramidal tract were faded. Patients examined during the acute stage who later recovered from hemiparesis had no visible changes of the 3DAC image, whereas patients who recovered poorly showed distinct color fading in the pyramidal tract within 14 days following stroke. In conclusion, very fine anatomical structures are visible on 3DAC images, and it can be used as a diagnostic tool for the human brain.

[1H and 31P-magnetic resonance spectroscopy of cerebral infarction in rats]

Magnetic resonance spectroscopy (MRS) allows the noninvasive study of metabolism in vivo. In order to further understand the time course of biochemical changes during cerebral infarction, we performed the MRS study with pathological analysis. The left middle cerebral artery (MCA) was occluded in spontaneously hypertensive male rats (SHR) by the method of Tamura et al. The spectra were obtained from the infarcted hemisphere by placing the surface coils over the left side of the calvarium. 31P and 1H-MRS were performed at 3 hours, 24 hours and 7 days after MCA occlusion. Ischemic lesions caused by the left MCA occlusion extended into the parietal lobe and caudate putamen. After 3 hours of ischemia, vacuolated neurophils and shrunken neurons were observed. At 24 hours, these changes were severe. After 7 days, infiltration of monocytes and capillary hyperplasia were seen, and neurons had disappeared. At the acute stage of ischemia the phosphocreatine/inorganic phosphate (PCr/Pi) peak ratio decreased. After 7 days of ischemia, these changes became obscure. The intracellular pH (pHi) decreased after 3 hours of ischemia and recovered almost to the control level at 24 hours post ischemia. Alkalosis was apparent 7 days after ischemia. This alkalosis might be due to increased permeability of the deteriorated blood brain barrier. Although the lactate level was high 24 hours post ischemia, the pHi was almost normal. The N-acetylaspartate/creatine ratio decreased significantly from the acute stage of stroke. This decrease correlated with pathological changes. The correlation of the magnetic resonance spectra with the histological results may opens aspects for monitoring stroke therapy and a new approach to tissue characterization.

Incidence and clinical significance of linear defects ascribed to interrenuncular septa on 99Tcm-DMSA SPET

99Tcm-dimercaptosuccinic acid (99Tcm-DMSA) planar and single photon emission tomographic images from 100 children were reviewed to analyse whether linear defects corresponding to anatomical characteristics of interrenuncular septum (IRS) could be seen. Thirty sites in 30 kidneys (20 right, 10 left) from 27 patients were determined as showing IRS. They were seen less frequently in patients less than 7 years of age. The prevalence of IRS in the patients with vesico-ureteric reflux (VUR) was not significantly different from that in the patients without VUR. The interrenuncular septum was never seen on planar images and was most clearly demonstrated on conventional coronal tomographic images. The linear defects ascribed to IRS on 99Tcm-DMSA scintigrams were of a similar incidence to that reported previously. However, IRS is still an unestablished structure, and there is no evidence that these linear defects actually correspond to the structure described as the interrenuncular septum.

Changes in serum myosin light chain I following aortocoronary bypass operations

The changes in myosin light chain I (MLC I) following aortocoronary bypass were studied in 31 patients and the curves of these changes were classified into three different patterns. A peak level of 14.7 +/- 1.54 ng/ml was seen in seven patients on postoperative day (POD) 2 which decreased suddenly to less than twice the normal value by POD 7 (group 1). Another 19 patients showed a peak level of 20.7 +/- 16.5 ng/ml on POD 5, which decreased slowly and was still high even by POD 7 (group 2). The remaining five patients developed only a slight increase in the MLC I level after the operation, with a peak value of 5.5 +/- 0.8 ng/ml (group 3). Creatine kinase myocardial band and glutamic oxaloacetic transaminase also remained low in this group. No correlation existed between the peak value of MLC I and the aortic cross-clamping time, or between the peak value of MLC I and the cardiopulmonary bypass time. Furthermore, the difference in cardiac output before and after the operation did not significantly differ among the three groups. These findings indicate that the measurement of MLC I is useful for diagnosing perioperative myocardial damage and may also be useful in the study of myocardial protection.

[Determinants of homologous blood utilization in addition to autologous blood transfusion--a multivariate study]

Since April 1989, we have been using autologous blood donation in order to avoid homologous blood transfusion as much as possible. To determine the factors which influence the necessity for homologous blood transfusion as well as autologous blood donation. Of them 77.6% (group 1) required autologous blood only, but others needed homologous blood transfusion as well as autologous blood. Using an invert analysis, preoperative factors that showed significant differences were age, body weight, number of autologous blood donations, amount of donated autologous blood, preoperative Hb and Ht. Among operative factors, aortic cross clamping time, cardiopulmonary bypass time, amount of concentrated blood from CPB circuit, amount of transfused autologous blood and amount of drainage demonstrated significant differences between groups. Univariately significant factors were studied by multivariate discriminant analysis. Total amount of drainage proved to be the best contributor of non-homologous blood transfusion surgery, followed by preoperative Hb, body weight, amount of concentrated blood from CPB circuit and amount of donated autologous blood in order of contribution Understanding these factors, homologous blood transfusion requirement may be greatly reduced. This is thought to be the largest series of autologous blood donation in Japan.

[Immunocytochemical and ultrastructural study of saphenous vein, internal thoracic artery, and right gastroepiploic artery in coronary artery bypass grafting]

The arterial conduits such as internal thoracic artery (ITA) and right gastroepiploic artery (GEA) are widely used in coronary artery bypass surgery because of their resistance to atherosclerosis. In this study, immunophenotypes of smooth muscle cells (SMCs) in intima and media of ITA, GEA and saphenous vein (SV) were studied using monoclonal antibodies specific to cytoskeletal proteins; actin (A), vimentin (V) and desmin (V). In addition, the ultrastructures of endothelium of these vessels were examined. The most SMCs in intima and media of ITA and GEA were found positive for (A) and (V) but negative for (D). In contrast, the majority of SMCs both in intima and media of SV were found positive for (A), (V) and (D). The ultrastructure of endothelium of ITA and GEA showed the deeper penetration of cytoplasmic process than SV, which might anchor the endothelium. We suggest the morphological difference of endothelium and phenotypic diversity of SMCs between arterial and venous grafts may account for the different susceptibility to atherosclerotic changes in coronary bypass grafting.

Study on the erythrocytes from myotonic dystrophy with multi-nuclear NMR

We have studied the water permeability through membranes, the function of the Na pump, and glucose metabolism of erythrocytes of patients with myotonic muscular dystrophy (MyD) using 1H--, 23Na, and 13C-NMR techniques. A significant decrease in water permeability was recognized in the MyD erythrocyte membrane, and impaired Na pumping was suspected to be correlated with the former biochemical abnormalities in band III protein of MyD erythrocyte membrane. Significant acceleration of glycolysis in the erythrocyte for the first 160 minutes was also recognized in MyD; however, the production of lactate showed no difference between MyD and controls. The increased glucose uptake in MyD may be compensatory to the diminished pumping mechanism, but further information, such as inorganic phosphate permeability and the activity of the rate-limiting enzyme of erythrocyte glycolysis, is needed.

Influence of age on left ventricular performance during exercise in normal Japanese subject: assessment by radionuclide ventriculography

To assess the effects of age on left ventricular performance, multistage supine ergometer exercise radionuclide ventriculography (RNV) was performed in 92 normal subjects. The subjects ranged in age from 24 to 86 years and were free of cardiopulmonary disease and diabetes. Age-related changes in exercise duration, left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), cardiac output (CO) left ventricular ejection fraction (LVEF), left ventricular dv/dt, systolic and diastolic time indexes of dv/dt, and peak systolic pressure/left ventricular end-systolic volume (PSP/LVESV) were analyzed at rest and during the peak exercise stage. Age-related decrease in LVEDV and peak diastolic dv/dt were significant at rest. The time indexes of ECG R to peak systolic dv/dt and time of end-systole to peak diastolic dv/dt also were prolonged with age. Both maximum heart rate and exercise duration were shown to decline with age. No age-related difference was observed in LVESV, LVEF or PSP/LVESV either at rest or during exercise. However, the change of LVEF and LVESV during exercise was less in subjects aged 60 or more. These results indicate decreased left ventricular function during exercise in elderly subjects.

Radionuclide assessment of left ventricular function during dobutamine infusion in patients with coronary artery disease: comparison with ergometer exercise

The effects of dobutamine on left ventricular function were assessed employing radionuclide ventriculography (RNV) in 7 normal subjects (Group 1) and 21 patients with coronary artery disease (Group 2). After routine bicycle ergometer exercise RNV, dobutamine infusion was started at 5 micrograms/kg/min and the dosage was increased by 5 micrograms/kg/min every 4 minutes to a total of 15 micrograms/kg/min. In Group 1, left ventricular ejection fraction (LVEF) increased by both ergometer exercise and dobutamine infusion. In Group 2, LVEF did not increase during exercise, but increased during dobutamine infusion without evidence of significant myocardial ischemia. Only 2 patients in Group 2 had new regional wall motion abnormality. Left ventricular end-diastolic volume (LVEDV) in Group 2 increased from 191 +/- 19 to 210 +/- 18 ml during ergometer exercise, but decreased from 193 +/- 18 to 153 +/- 19 ml during dobutamine infusion. Short-term low-dose infusion of dobutamine may be used in patients without evidence of significant myocardial ischemia, but probably cannot be substituted for exercise testing in patients with mild to moderate coronary artery disease.

Reversal of rest asynergy during exercise in patients with coronary artery disease

The diagnosis of ischemic heart disease by radionuclide ventriculography (RNV) is performed on the basis of an abnormal response of the left ventricular ejection fraction and the occurrence, or aggravation, of regional wall motion abnormality during exercise. However, the abnormal wall motion observed by RNV at rest is improved in some patients with coronary artery disease during exercise. We examined the clinical features of such patients who showed a paradoxical response of regional wall motion. The left ventricle was divided into 4 segments: anteroseptal, apical, inferior and posterolateral. The degree of wall motion of each segment was classified into 5 grades and scored according to a 5 point system: 4 = normokinesis, 3 = hypokinesis, 2 = severe hypokinesis, 1 = akinesis and 0 = dyskinesis. The wall motion score (WMS) was calculated as the sum of each segment score. If the WMS increased by 2 points or more during exercise, the case was defined as having shown significant improvement of wall motion. Improvement in WMS was found in 26 (12%) of 209 serial patients who underwent exercise RNV, exercise thallium myocardial scintigraphy and coronary angiography. Clinically, half of these patients had a variant form of angina pectoris. With respect to coronary lesions in the segments with reversible asynergy, 12 patients had 0 vessel disease, 8 had lesions with stenosis of less than 75% and 3 showed an adequate collateral circulation. Redistribution found on the exercise thallium myocardial scintigram at the same sites of improved wall motion was identified in only 1 patient. An analysis of patients with paradoxical improvement of wall motion during exercise suggests the involvement of coronary spasm, an improvement of coronary flow reserve, such as could be produced by regression or recanalization of the main lesions, or establishment of significant collateral circulation.

Incidence and clinical course of right ventricular infarction: assessment with radionuclide ventriculography

The incidence and prognosis of right ventricular infarction were studied by radionuclide ventriculography (RNV) in 50 consecutive cases of acute myocardial infarction. RNV was performed within thirty-six hours of symptoms and one month after onset. Right ventricular infarction was absent in all 25 patients with anterior infarction. It was found in 15 of the 25 patients with inferior infarction, accompanied by a marked reduction in right ventricular ejection fraction (28 +/- 8%), but was notably alleviated one month later with normalization of right ventricular ejection fraction (39 +/- 7%) and wall motion. These phenomena seem to be specific in right ventricular infarction.

[Myocardial ischemia with negative stress electrocardiography: evaluation by stress RI studies]

Patients with negative stress electrocardiography (ECG) (no ST segment depression) were re-evaluated by means of stress RI studies including 201T1 single photon emission computed tomography (SPECT) and 99mTc-RBCs radionuclide ventriculography (RNV). Four hundred seven patients, including 303 with old myocardial infarction (OMI; SPECT: 188, RNV: 115) and 104 with effort angina (EA; SPECT: 58, RNV: 46), all of whom underwent left ventriculography and coronary arteriography, were re-evaluated by symptom-limited graded bicycle ergometer exercise RI testing. The results were as follows: 1. Among those with negative stress ECG (53% of OMI and 31% of EA), 54% and 73% of OMI and EA, respectively, had positive SPECT. 2. Among those with negative stress ECG (56% of OMI and 39% of EA), 70% and 39% of OMI and EA, respectively, had positive delta EF (poor increase in ejection fraction: delta EF less than 5%) and, 41% and 28% of OMI and EA had deteriorated regional wall motion. 3. Those with OMI and negative ECG showed no correlations with the numbers of diseased vessels, infarcted sites, or ischemic areas. In conclusion, RI testing appears to be a significantly more sensitive means of detecting stress-induced ischemia, compared to stress ECG.

[Acute right ventricular infarction: assessment with radionuclide ventriculography]

The clinical significance of right ventricular (RV) infarction has been neglected compared with left ventricular infarction. In recent years, however, the clinical importance of RV function in the treatment of myocardial infarction has been well recognized. We performed prospective radionuclide studies to assess the incidence and prognosis of RV infarction in 50 cases of initial acute myocardial infarction (25 cases of anterior and 25 of inferior infarction). Radionuclide ventriculography was performed within the first two days after onset of symptoms, and repeated one-two weeks and one month after the attack, respectively. RV infarction was diagnosed by the presence of severe RV regional wall motion abnormalities and positive signs of at least one of the following diagnostic signs: ST elevation at V4R in the ECG, positive 99m-technetium pyrophosphate myocardial scintigram at the RV free wall, and positive right heart catheterization findings. Results were as follows: 1. RV infarction was documented in 15 of 25 cases with inferior infarction, but there were no cases in anterior infarction. 2. There were no remarkable changes of RV ejection fraction (EF) in anterior myocardial infarction during one month (41% +/- 8% in acute phase and 43 +/- 8% in four weeks later). However, RVEF was markedly improved from 34 +/- 11% during first two days, to 38 +/- 7% during one-two weeks, and 39 +/- 8% four weeks after the attack, in cases of inferior infarction with RV infarction. Without RV infarction, RVEF in cases of inferior infarction did not show improvement. 3. In 11 of 15 cases with RV infarction, RV regional wall motion abnormalities improved to the normal range, which seemed to contribute to the improvement of RVEF. 4. Hemodynamic findings with Swan-Ganz catheters showed typical findings compatible with RV infarction only in seven of 13 cases with RV infarction. Thus this finding implies that RV failure did not always accompany RV infarction. 5. Coronary arteriography revealed that right coronary arterial lesions proximal to the RV branch were documented in all 10 cases with RV infarction who had coronary arteriography. RV infarction, caused by deranged coronary blood flow at the RV branch of the right coronary artery, showed marked improvement of RVEF during four weeks after the attack in prospective radionuclide studies. This finding was not seen in left ventricular infarction. The pathophysiological mechanism of improvement of RVEF in RV infarction would be the difference of its coronary circulation compared with that of the left ventricle.(ABSTRACT TRUNCATED AT 400 WORDS)

Cardiac tamponade in rheumatoid arthritis. Successful treatment with intrapericardial steroid administration

Cardiac tamponade complicated by classic rheumatoid arthritis was markedly alleviated by pericardiocentesis and intrapericardial administration of steroid. For the following 2 years, no recurrence of cardiac tamponade or constrictive pericarditis was observed. According to the literature, only one other patient with cardiac tamponade complicating rheumatoid arthritis (RA) had been successfully treated patient by intrapericardial steroid administration.

Positive intratympanic pressure in the morning and its etiology

Intratympanic pressures were measured by tympanometer in forty ears free from disease. In the recumbent position, the first tympanogram was obtained in the morning at awakening, before swallowing. The second pressure measurement was performed in the upright position after swallowing and chewing. Twenty-two ears showed positive pressure in the middle ear before swallowing and decreased pressure after swallowing. The present results revealed no evidence of continuous gas absorption from the middle ear during sleep. The other experiment demonstrated that raising of the PCO2 level by hypoventilation increased the pressure in the middle ear. The results suggested indirectly a diffusion of carbon dioxide to the middle ear cavity from its surrounding tissue. The intratympanic pressure seems limited in part to the partial pressure gradient of gases between the middle ear cavity and its surrounding tissue when ventilation through the Eustachian tube is impaired.

[Right ventricular ischemia evaluated by radionuclide ventriculography]

The clinical usefulness of radionuclide ventriculography (RNV) was evaluated in patients with right ventricular ischemia. The subjects consisted of 25 patients with acute inferior myocardial infarction, 19 patients with old myocardial infarction and six patients with angina pectoris who had severe stenosis of the right coronary artery. In patients with acute inferior myocardial infarction, follow-up radionuclide studies were performed during the recovery periods on the first, 7th-14th, and 30th hospital day. Fifteen of the 25 patients initially had decreased right ventricular ejection fractions (evidence of right ventricular infarction). The mean value was 28 +/- 8% on the initial day, but 7-14 days and 30 days after the acute attack, it improved markedly to 36 +/- 9% and 39 +/- 9%, respectively. Regional wall motion abnormality resolved in 10 of the 15 patients on the 30th hospital day. In 25 patients with old myocardial infarction or with angina pectoris, RNV was performed at rest and during supine exercise to determine the influence or right coronary artery disease. Right ventricular ejection fraction was changed by exercise from 42 +/- 7% to 44 +/- 10% in patients with proximal artery lesions, and from 45 +/- 7% to 50 +/- 10% in patients with distal artery lesions. Right ventricular ejection fraction increased in patients with isolated right coronary artery disease (rest: 44 +/- 8%, exercise: 49 +/- 9%), decreased in patients with combined left anterior descending artery disease (rest: 40 +/- 6%, exercise: 38 +/- 11%) and increased in patients with combined circumflex artery disease (rest: 43 +/- 5%, exercise: 47 +/- 6%). We concluded that right ventricular infarction is a frequent complication in patients with inferior myocardial infarction. However, right ventricular ejection fraction and right ventricular regional wall motion abnormality improve dramatically within one month. Stress-induced ischemia would be rare in patients with isolated right coronary artery disease. The above findings support the notion that the right ventricular myocardium has peculiar coronary perfusions.

[Quantitative analysis of aortic regurgitation using radionuclide phase analysis]

In this study, the clinical utility of phase analysis using gated blood pool scintigraphy to detect aortic regurgitation (AR) was assessed. The study population included 33 patients with AR documented by cineaortography, and 53 patients without AR diagnosed by clinical features and pulsed Doppler echocardiography or cineaortography. Gated blood pool images were stored in modified left anterior oblique views by the multiple gated method (28 frames per beat) after the in vivo labeling of erythrocytes using 25 mCi 99m-Tc. Amplitude was depressed at the subaortic region toward the apex in patients with AR, and occasionally the phase angle occurred earlier in the same region. This is because diastolic filling began earlier and stroke count was decreased more in the subaortic region than in other regions of the left ventricle in examining the regional time-activity curve. Based on this characteristic finding in the amplitude image, the specificity was 81% and the sensitivity was 79% in the diagnosis of AR. The degree of AR was estimated using the amplitude image as follows: grade 1, depression of amplitude localized to the subaortic region; grade 2, depression of amplitude detected from the subaortic region to the midportion of the left ventricle; grade 3, depression of amplitude detected beyond the midportion of the left ventricle. We compared results with those of the radionuclide (RI's classification) and angiographic methods (Sellers' classification) as to the severity of AR. AR could not be detected using the radionuclide method in all four patients with Sellers' grade 1, and in three of nine patients with Sellers' grade 2.(ABSTRACT TRUNCATED AT 250 WORDS)

[Detection of thrombi by 111In-oxine platelet scintigraphy]

For 52 patients with cardiac disease and 11 patients with vascular disease, In-111-oxine platelet scintigraphy was performed to assess its clinical usefulness for detecting thrombi. Using Hayashida's method, platelets were separated in 43 ml peripheral blood, washed and labeled with 1 mCi In-111-oxine. In addition to planar images in the anterior, 45 degrees left anterior oblique and left lateral views, single photon emission computed tomography (SPECT) was performed in some cases by rotating a dual gamma camera 24 and 72 hours after labeled platelet injection. The functions of platelet and coagulability were examined 36 hours after the injection of labeled platelets. Medical therapy was not changed during this study. Intracardiac thrombi were documented in 16 of 52 cases with cardiac disease and intravascular thrombi in 10 cases with vascular disease by angiography, CT and two-dimensional echocardiography. Positive images were obtained in 10 cases with cardiac disease and in eight cases with vascular disease by scintigraphy. Therefore, sensitivity, specificity, and overall accuracy were 63%, 100% and 88% in intracardiac thrombi; 80%, 100% and 82% in intravascular thrombi; and totally 69%, 100% and 87%, respectively. In the detection of intracardiac thrombi by scintigraphy, the sensitivity seemed to be lower and the specificity higher than those by other graphic studies. In 52 cases with cardiac disease, five out of six cases with false negative images had received antiplatelet and/or anticoagulant drugs, and in these cases, platelet and coagulation functions tended to be decreased compared with those of true positive cases or true negative cases. We conclude that positive images in scintigraphy indicate the existence of growing thrombi, and that In-111-oxine platelet scintigraphy has clinical usefulness, not only for detecting thrombi, but for estimating platelet activity and effect of medical therapy.

Supraclavicular brachial plexus block using a nerve stimulator and an insulated needle

A technique employing a nerve stimulator and an insulated needle was used for supraclavicular brachial plexus block in 71 patients using 0.5% plain bupivacaine 15-20 ml. The mean minimal stimulating current to produce paraesthesia was 0.09 mA. The plexus was identified at a mean depth of 27 mm below the skin. The block was successful in 98% of patients when the stimulation was felt in the index, middle or ring finger, but was often incomplete when felt in the thumb or little finger.