Treatment of Acute Myocardial Infarction with Cardiogenic Shock using Left Ventricular Assist Device

We have treated ten cardiogenic shock patients after acute myocardial infarction (AMI) with a left ventricular assist device (LVAD). These patients were later divided into three groups: the first group with ventricular septal perforation, the second with aorto-coronary bypass grafting (ACBG) before LVAD implantation and the third group without ACBG. LVAD maintained the systemic circulation in each group, and cardiac function recovered enough to remove LVAD in 70% of the total patients. Two of three patients in the first group were discharged from hospital. Two weaned cases in the second group died of multiple organ failure and one was discharged, and hemorrhagic necrosis was seen in the bypassed area of the myocardium. One patient of the third group could not be weaned from LVAD because of respiratory failure though his heart function began to recover. Another case in the third group underwent bypass grafting after removal of LVAD. However ACBG surgery should be done very carefully because a patient in shock is occasionally intolerant to major surgery. In all groups, the major cause of death was multiple organ failure which was probably caused by the prolonged low output condition prior to LVAD application. In the light of this experience, it appears that LVAD should be applied before irreversible damage occurs to major organs, including the heart itself. To ensure the timely application of LVAD, some way must be found to introduce systematic application of LVAD into the normal course of AMI treatment.

Skin recruitment of monomyeloid precursors involves human herpesvirus-6 reactivation in drug allergy

BACKGROUND

In drug-induced hypersensitivity syndrome (DIHS), latent human herpesvirus (HHV)-6 is frequently reactivated in association with flaring of symptoms such as fever and hepatitis. We recently demonstrated an emergence of monomyeloid precursors expressing HHV-6 antigen in the circulation during this clinical course.

METHODS

To clarify the mechanism of HHV-6 reactivation, we immunologically investigated peripheral blood mononuclear cells (PBMCs), skin-infiltrating cells, and lymphocytes expanded from skin lesions of patients with DIHS.

RESULTS

The circulating monomyeloid precursors in the patients with DIHS were mostly CD11b(+) CD13(+) CD14(-) CD16(high) and showed substantial expression of skin-associated molecules, such as CCR4. CD13(+) CD14(-) cells were also found in the DIHS skin lesions, suggesting skin recruitment of this cell population. We detected high levels of high-mobility group box (HMGB)-1 in blood and skin lesions in the active phase of patients with DIHS and showed that recombinant HMGB-1 had functional chemoattractant activity for monocytes/monomyeloid precursors in vitro. HHV-6 infection of the skin-resident CD4(+) T cells was confirmed by the presence of its genome and antigen. This infection was likely to be mediated by monomyeloid precursors recruited to the skin, because normal CD4(+) T cells gained HHV-6 antigen after in vitro coculture with highly virus-loaded monomyeloid precursors from the patients.

CONCLUSIONS

Our results suggest that monomyeloid precursors harboring HHV-6 are navigated by HMGB-1 released from damaged skin and probably cause HHV-6 transmission to skin-infiltrating CD4(+) T cells, which is an indispensable event for HHV-6 replication. These findings implicate the skin as a cryptic and primary site for initiating HHV-6 reactivation.

Factors modifying the frequency of spontaneous activity in gastric muscle

The cellular mechanisms that determine the frequency of spontaneous activity were investigated in gastric smooth muscles isolated from the guinea-pig. Intact antral muscle generated slow waves periodically; the interval between slow waves was decreased exponentially by depolarization of the membrane to reach a steady interval value of about 7 s. Isolated circular muscle bundles produced slow potentials spontaneously or were evoked by depolarizing current stimuli. Evoked slow potentials appeared in an all-or-none fashion, with a refractory period of approximately 2-3 s. Low concentrations of chemicals that modify intracellular signalling revealed that the refractory period was causally related to the activity of protein kinase C (PKC). Activation of PKC increased and inhibition of PKC activity decreased the frequency of slow potentials. Chemicals that inhibit mitochondrial functions reduced the frequency of slow waves. Inhibition of internal Ca(2+)-store activity decreased the amplitude, but not the frequency of slow potentials, suggesting that the amplitude is causally related to Ca(2+) release from the internal store. The results suggest that changes in [Ca(2+)](i) caused by the activity of mitochondria may play a key role in determining the frequency of spontaneous activity in gastric pacemaker cells.

Inhibitory actions of indomethacin on electrical and mechanical responses produced by nerve stimulation in circular smooth muscle of the guinea-pig gastric fundus

The effects of indomethacin on electrical and mechanical responses produced by transmural nerve stimulation (TNS) were investigated in isolated circular smooth muscle of the guinea-pig gastric fundus. TNS evoked a cholinergic excitatory junction potential (e.j.p.). The e.j.p.s were inhibited by 1-10 microM indomethacin, in a concentration-dependent manner, with no marked alteration of the resting membrane potential. Exogenously applied acetylcholine caused a depolarization of the membrane that was not altered by indomethacin. TNS evoked a cholinergic twitch contraction at low frequencies (0.1 Hz). A train of TNS's at high frequency (1 Hz) produced a transient contraction with a subsequent sustained relaxation. Indomethacin reduced the resting tension and inhibited these TNS-induced contractions. Application of Nomega-nitro-L-arginine (NOLA), an inhibitor of nitric oxide (NO) synthesis, increased the amplitude of twitch contractions, and altered transient contractions to tetanic contractions during TNS at a frequency of 1 Hz, also with an increased amplitude. In the presence of NOLA, indomethacin (5 microM) again reduced the resting tension and inhibited TNS-induced contractions. This inhibition was greater for twitch contractions than for tetanic contractions. Nifedipine reduced the TNS-induced contractions, while addition of indomethacin further reduced the amplitude of contractions. Contractions produced by low concentrations of acetylcholine (0.1 microM) were inhibited by indomethacin, while those produced by 1 microM were not. These results indicate that the inhibitory actions of indomethacin on TNS-induced contractions do not involve enhanced production of NO or selective inhibition of voltage-gated Ca-channels. Prejunctional autoregulatory mechanisms may also not be altered by indomethacin. As indomethacin inhibits the enzyme cyclooxygenase, it is speculated that endogenously produced prostaglandins exert excitatory actions on gastric smooth muscle, and act mainly postjunctionally to facilitate spontaneous and neurogenic electrical and mechanical activity.

Doppler sonography of hepatic arterial blood flow velocity after percutaneous transhepatic portal vein embolization

OBJECTIVE

This study was conducted to elucidate the changes in hepatic arterial blood flow after portal vein embolization.

SUBJECTS AND METHODS

We prospectively measured the flow velocity and resistive index of the common, right, and left hepatic arteries, using Doppler sonography, in 21 patients who underwent embolization of the right portal vein. The measurements were performed before and 1, 3, 5, 7, and 14 days after embolization. We assessed the changes in liver volume with a volumetric study using CT.

RESULTS

After embolization, flow velocity in the common hepatic artery increased significantly (p < 0.0001). Flow velocity in the right hepatic artery also increased significantly (p < 0.0001), with a significant decrease in resistive index (p < 0.0001). The flow velocity and resistive index of the left hepatic artery were unchanged. The increase in flow velocity in the right hepatic artery significantly correlated with that in the common hepatic artery (r = 0.514, p < 0.05). The calculated volume of the embolized right hepatic lobe significantly (p < 0.0001) decreased, from 685 +/- 32 cm(3) before embolization to 568 +/- 28 cm(3) after embolization. The atrophy rate of the right hepatic lobe significantly correlated with the increase in flow velocity in the right hepatic artery (r = 0.700, p < 0.0005).

CONCLUSION

Portal vein embolization induces an increase in hepatic arterial blood flow velocity in the embolized hepatic segments, resulting from an increase in common hepatic arterial flow, but not from a steal phenomenon due to decreased hepatic arterial blood flow in the nonembolized hepatic segments. This observation may be explained by the simple mechanical effect of interposing a slower flowing stream (portal flow) in the path of a faster flowing stream (arterial flow).

Asymptomatic portal vein obstruction after hepatobiliary resection: early detection by Doppler ultrasonography

We report two different types of portal vein obstruction after liver resection: portal vein thrombosis due to steal phenomenon via a splenorenal shunt, and kinking of the skeletonized left portal vein after right hepatic lobectomy with caudate lobectomy. The two cases of portal vein obstruction were asymptomatic without any suggestive laboratory findings. Only routine Doppler ultrasonography detected portal vein obstruction which was successfully treated by emergency operation.

The quantitative analysis of three action modes of volatile anesthetics on purple membrane

We quantitatively assessed the spectroscopic changes of purple membrane in relation to the concentrations of a volatile anesthetic. As reported previously, volatile anesthetics show three modes of action on purple membrane. By using an anesthetic for which the concentration in solution could be determined spectroscopically and by applying modified analytical methods regarding the M-intermediate lifetime, we were able to clarify the quantitative relation between anesthetic concentration and each mode of action, a relation which in the past has only been described qualitatively. We also determined through the measurement of transient pH changes with pyranine that the proton pump efficiency per photochemical cycle in an action mode induced with low concentrations of anesthetic does not change from that of the native state. Moreover, we dynamically obtained the individual M-bacteriorhodopsin difference spectrum of each state at room temperature using our flash photolysis system equipped with a wavelength-tunable dye laser. These results demonstrated again that we should clearly distinguish different action modes of anesthetics according to their concentrations.

Structural and functional differences of two forms of GTP-binding protein, Gq, in the cephalopod retina

The major GTP-binding protein (G-protein) in the rhabdomeric photoreceptor membranes of the squid (Watasenia scintillans) has been identified as a Gq-class G-protein. Anti-Gq alpha antibodies recognized a protein not only in the photoreceptor membranes but also in soluble fractions of the retina. The 42 kD protein in the soluble fractions (soluble Gq alpha) had the same molecular mass and the same reactivities to anti-Gq antibodies as those of membrane-bound Gq alpha. The G beta subunit was scarcely detected in the soluble fractions, being found mostly in the membrane fraction, indicating soluble Gq alpha exists in monomeric form. Soluble Gq alpha had no effect on the GTPase activity of the photoreceptor membranes, suggesting that it does not interact with photoactivated rhodopsin or G beta gamma. Soluble Gq alpha would be an inactive form of Gq alpha. In the retina of Octopus fangsiao, soluble Gq alpha was scarcely detected after dark adaptation, but increased during subsequent light exposure and decreased on returning to dark adaptation. These results with Octopus suggest that functional membrane-bound Gq alpha is converted to soluble Gq alpha on exposure to light. Transformation of membrane-bound Gq alpha into the soluble form by hydroxylamine suggests that the difference between membrane-bound and soluble Gq alpha is associated with the attachment of fatty acid(s).

Regulation of squid visual phospholipase C by activated G-protein alpha

Phospholipase C (PLC) is the key enzyme in the phototransduction cascade of invertebrate rhabdomeric photoreceptors. In addition to 130 kDa PLC, a 95 kDa protein recognized by antibody against the catalytic site of PLC was found in the squid retina. The PLC-like 95 kDa protein (95 kDa PLC) was produced from 130 kDa PLC by an intrinsic protease in the presence of calcium. The 130 kDa PLC was stimulated by the active form of Gq-class G-protein alpha (Gq alpha), but the 95 kDa PLC was not, although their PLC activity was similar. A 35 kDa fragment, the counterpart of 95 kDa PLC, was not recognized by antibodies against catalytic site or N-terminal site of the 130 kDa PLC, indicating that the cleavage site is on the C-terminal side beyond the catalytic site. In the presence of a large excess of the 35 kDa fragment, 95 kDa PLC was stimulated by Gq alpha to a similar extent as intact 130 kDa PLC. These results indicate that the C-terminal polypeptide of PLC is necessary for regulation of its enzyme activity by Gq alpha. The uncoupling of PLC from Gq alpha, caused by limited proteolysis, is therefore a candidate regulatory mechanism of the phototransduction cascade in rhabdomeric photoreceptors.

Binding of volatile anesthetics to purple membranes studied by X-ray diffraction

Volatile anesthetics, diiodomethane and trifluoroethyl iodide, acted on the purple membrane of Halobacterium halobium in two different modes depending on the concentration. At low concentration, the absorption maximum of bacteriorhodopsin shifted from 561 to 558 nm (BR558) and the M-intermediate of the photocycle decayed faster than the native one. Higher concentration induced a species absorbing maximally at 480 nm (BR480) and the long-lived M-intermediates. The X-ray study suggested that anesthetics bound specifically to the protein-lipid interfacial region within a trimer near the surface of membrane in BR558 and entered into the hydrophobic domain of the membrane in BR480.

Effects of dopamine on veins in humans: comparison with noradrenaline and influence of age

OBJECTIVE

To compare the venoconstricting effect of dopamine with that of noradrenaline and to investigate the influence of age on the responsiveness to dopamine in human subjects.

METHODS

In eight young and eight elderly male subjects, increasing doses of dopamine or noradrenaline were infused into a dorsal hand vein and its diameter was measured using a linear variable differential transformer.

RESULTS

There was no significant difference between the maximum venoconstriction (Emax) for dopamine and that for noradrenaline. The infusion rate to induce 50% of Emax (ED50) for dopamine in the young and elderly subjects was 363 ng x min(-1) and 352 ng min(-1), and the ED50 for noradrenaline was 40.7 ng min(-1) and 43.8 ng x min(-1), respectively. Neither in the Emax nor in the ED50 for these drugs were there significant differences between the young and elderly subjects.

CONCLUSION

The venoconstricting effect of dopamine is 5-20 times less than that of noradrenaline, and aging does not influence the responsiveness to dopamine and noradrenaline in human subjects.

Role of glucocorticoid in the upregulation of type I interleukin-1 receptor mRNA expression in hepatocytes of endotoxin-administrated mice

The interleukin-1 (IL-1) signal is transduced through type I IL-1 receptor (IL-1RI). We have recently reported that lipopolysaccharide (LPS) upregulated IL-1RI mRNA expression in mouse liver in vivo and that IL-1 and IL-6 directly upregulated IL-1RI mRNA expression in primary cultured mouse hepatocytes. Glucocorticoid (GC) has been reported to increase IL-1 binding to the cell surface and the expression level of IL-1R mRNA in a variety of cell types. As serum GC level is elevated in an inflammatory response, we evaluated the role of GC in LPS-induced upregulation of IL-1RI mRNA in the mouse liver. When LPS was administered to adrenalectomized (ADX) mice, IL-1RI mRNA was upregulated at a level comparable to those of untreated or sham-operated mice. A high dose of dexamethasone (Dex), however, caused upregulation of the mRNA. When primary cultured mouse hepatocytes were treated with Dex, only a weak upregulation of IL-1RI mRNA was observed. However, Dex in combination with IL-1 or IL-6 markedly enhanced the IL-1RI mRNA expression. A marked upregulation of the mRNA was also induced by treatment with a combination of IL-1 and IL-6 in the absence of Dex, reflecting the observation in ADX mice. These results suggest that the upregulation of IL-1RI mRNA in response to LPS is induced by the interaction of IL-1 and IL-6 and that GC augments their effect.

A novel yeast gene, RHK1, is involved in the synthesis of the cell wall receptor for the HM-1 killer toxin that inhibits beta-1,3-glucan synthesis

The HM-1 killer toxin from Hansenula mrakii is known to inhibit cell wall beta-1,3-glucan synthase of Saccharomyces cerevisiae and other sensitive strains of yeast. A number of mutants of Saccharomyces cerevisiae that show resistance to this toxin were isolated in order to clarify the killing mechanism of the toxin. These mutants, designated rhk (resistant to Hansenula killer), were classified into three complementation groups. A novel gene RHK1, which complements the killer-resistant phenotype of the largest complementation group rhk1, was isolated. DNA sequence analysis revealed an open reading frame that encodes a hydrophobic protein composed of 458 amino acids. Gene disruption followed by tetrad analysis showed that RHK1 is not essential and loss of RHK1 function endowed S. cerevisiae cells with complete killer resistance. A biochemical analysis suggested that RHK1 does not participate directly in the synthesis of beta-1,3-glucan but is involved in the synthesis of the receptor for the HM-1 killer toxin.

Molecular cloning, purification and characterization of two endo-1,4-beta-glucanases from Aspergillus oryzae KBN616

Two endo-1,4-beta-glucanase genes, designated celA and celB, from a shoyu koji mold Aspergillus oryzae KBN616, were cloned and characterized. The celA gene comprised 877 bp with two introns. The CelA protein consisted of 239 amino acids and was assigned to the cellulase family H. The celB gene comprised 1248 bp with no introns. The CelB protein consisted of 416 amino acids and was assigned to the cellulase family C. Both genes were overexpressed under the promoter of the A. oryzae taka-amylase A gene for purification and enzymatic characterization of CelA and CelB. CelA had a molecular mass of 31 kDa, a pH optimum of 5.0 and temperature optimum of 55 degrees C, whereas CelB had a molecular mass of 53 kDa, a pH optimum of 4.0 and temperature optimum of 45 degrees C.

Clinical experience of percutaneous cardiopulmonary support

Recently, percutaneous cardiopulmonary support (PCPS) combined with femoro-femoral bypass without reservoir has become valued because of its quick and easy application. We developed a fully preconnected compact integrated cardiopulmonary bypass (CPB) unit (priming volume of 250 ml) with a blind pore membrane oxygenator (Kuraray Menox) for PCPS. From 1990 to 1995, PCPS was performed in 49 patients of whom 26 were weaned from support. In most cases, we applied this CICU in patients with no active bleeding (22 patients); in patients with active bleeding (n = 13), we used Medtronic's heparin-bonded close chest support pack (CCSP). Of these, PCPS was performed uneventfully for 2 h (median) in 8 elective cases; all of these patients were weaned or were switched to a left ventricular assist system (LVAS). In 8 urgent cases, such as those with low cardiac output syndrome, PCPS was performed for 4 days (median), 1 was weaned, and 2 CICU were cases switched to other procedures. In 32 cases of shock, 5 CICU patients were weaned, and 3 of them survived. Eight patients including 5 CICU patients and 1 CCSP patient were switched to operation or LVAS, and 2 CICU patients remain alive. From these data, PCPS has been shown to support the patient's circulation in the acute phase and earn time to switch to operation or LVAS; the quick and easy set-up of the CICU can improve the clinical results. The use of the Medtronic device broadened the indication for PCPS. The CCSP enlarged the indication of PCPS but could not improve the results. To improve the results, a heparin-bonded surface is desired.

[Clinical study of re-do surgery after Bentall-type operation]

Among patients who underwent reconstruction of the aortic root by Bentall-type procedure using a composite graft, we investigated patients who underwent reoperation for complications related to composite graft. We employed composite graft reconstruction of the aortic root in 155 patients for 16 years prior to December 1994. Annulo-aortic ectasia was observed in 112 patients, aortic dissection in 34, and aortitis without aneurysm formation in 9. The original Bentall procedure was performed in 36, the Cabrol method in 8, the interposition method in 26, and the Carrel patch method in 85 patients. Thirteen (8.4%) of these patients required reoperation for complications related to the composite graft. Three of 4 patients with graft infection early after surgery underwent reconstruction with composite graft, but died in the hospital. The remaining patient survived after combined treatment that included the graft washing with Iodine (Isozin) solution and omentopexy. Four patients developed pseudoaneurysm formation due to sutural insufficiency and 7 has prosthetic valve failure as late complications. Three of the 4 patients with pseudoaneurysm underwent reconstruction with a second composite graft by the interposition method, while one patient with aortitis required another reoperation. In the remaining one patient, the leak was directly close along with second aortic valve replacement. All prosthetic valves used in 7 patients with prosthetic valve failure were Ionescu-Shiley biological valves. Primary tissue failure was observed in 6 and prosthetic valve endocarditis in one patient. Second cardiac valve replacement using a mechanical valve was possible. All the patients who underwent late reoperation showed favorable results. Infection of the composite graft showed the poor prognosis, and prevention of infection is important. Sutural insufficiency at the anastomosed site can be prevented by appropriate surgical procedures such as reinforcing suture, but further countermeasures for sutural insufficiency were considered necessary for aortitis in conditions, such as Behcet's diseases.

[Valvular surgery in the patients more than 70 years old]

One hundred twenty-eight valvular surgeries in patients over 70-year-old were reviewed (AVR:58, MVR:38, AVR and MVR: 11, mitral valvuloplasty (MVP): 11, AVR + MVP:11, mitral valvuloplasty (MVP): 11, AVR + MVP: 8, others: 2). Concomitant CABG was performed in 7, Maze in 6, TVR in 5 and Bentall in 3 cases. Early deaths occurred in 17 patients (13%). The early mortality was 5% in AVR, 21% MVR, 18% in AVR and MVR, 0% in MVP and 38% in AVR and MVP. Late death occurred in 16 patients. Forty-three percent of the late deaths were cardiac death. The actuarial survival at 10 years was around 50% in all groups. In the aortic position, a mechanical valve was implanted in 47 cases and a bioprosthetic valve was implanted in 33 cases. In the mitral position, the mechanical valve was implanted in 37 cases and the bioprosthetic valve was implanted in 12 cases. The event free rate after AVR at 10 years was 37% in patients with the mechanical valve (3 cerebral hemorrhage, 2 PVE, 1 thromboembolism and 1 sudden death) and 46% in patients with the bioprosthetic valve (2 PVE and 1 primary tissue failure). The event free rate after MVR at 10 years was 84% in patients with mechanical valves (1 perivalvular leak, 1 PVE and 1 sudden death) and 75% in patients with bioprosthetic valves (1 PVE and 1 sudden death). Between mechanical valve group and bioprosthesis group, no statistically significance was found in the event free curve after AVR nor MVR. There was no valve related event after MVP. Considering the better durability of bioprostheses in the aortic position than in the mitral position, the presence of atrial fibrillation and necessity of warfarin anticoagulation, we conclude that a choice of a bioprosthetic valve could be acceptable in the aortic position, but may not be recommended in the mitral position.

Ten-year experience with the Carpentier-Edwards pericardial xenograft in the tricuspid position

We reviewed the cases of 66 patients who underwent 67 tricuspid valve replacements with Carpentier-Edwards pericardial xenografts between April 1985 and January 1994. Average patient age at time of operation was 52 years (range 8 to 71 years). Concomitant mitral or aortic valve replacements were performed in 46 patients. There were 10 operative deaths and 6 late deaths. Actuarial survival at 9 years was 75.4% +/- 5.7%. Prosthetic valve endocarditis occurred twice in one patient. Reoperations for tricuspid regurgitation and for concomitant procedures (maze operation and repair for leak of the mitral prosthesis) were performed in two patients. In both cases, examination of the explanted prostheses showed that the tricuspid regurgitation was the result of nonstructural dysfunction caused by fibrous pannus formation on the cusps of the ventricular side. Among the survivors, 47 patients (92%) were in functional class I or II. Prosthetic valve function was studied by color Doppler echocardiography. Among 38 patients, tricuspid regurgitation more than grade 3/4 or transprosthetic gradient more than 5 mm Hg was found in 11. One patient had right heart failure and the others had no symptoms. In 10 years of experience with the Carpentier-Edwards pericardial xenograft, mortality and morbidity after tricuspid valve replacement were satisfactory. Echocardiographic examination revealed subclinical prosthetic dysfunction in 35% of patients who were followed up for longer than 5 years, however, and we believe that these patients should receive careful follow-up.

X-ray diffraction pattern from internal structure of bovine rhodopsin

Pure bovine rhodopsin pellets were prepared by removal of cholic acid from rhodopsin-cholic acid complex, and X-ray diffraction patterns from the internal structure of rhodopsin were obtained for the first time using wet and dry pellet samples. The peaks at around 10 and 4.3 A spacings observed for both samples can be attributed to alpha-helices in rhodopsin molecule, providing direct evidence of the helical structure of rhodopsin. A shoulder peak at around 34 A spacing was also observed for the dry pellet, which can be explained by the first-neighbor distance between rhodopsin molecules in the sample.

Aortic and mitral valve replacement with the Carpentier-Edwards pericardial bioprosthesis: 10-year results

BACKGROUND AND AIM OF THE STUDY

This report reviews our experience with single aortic and mitral valve replacement using the Carpentier-Edwards pericardial valve in a population younger than those of other reports.

METHODS

Between 1984 and 1993, 106 patients underwent single aortic or mitral valve replacement using a Carpentier-Edwards pericardial valve. There were 49 aortic and 57 mitral implants. The mean age was 56.7 +/- 14.3 years. The follow up was 100% complete; total follow up being 273.3 patient-years in the aortic (AVR) and 348.0 patient-years in the mitral valve replacement (MVR) group, with a mean of 5.6 and 6.1 years, respectively.

RESULTS

The rates of thromboembolic complications for AVR and MVR were 0.37% and 0.58% per patient year respectively. There were no cases of non-structural dysfunction or anticoagulant-related hemorrhage. The incidences of prosthetic valve endocarditis for AVR and MVR were 0% and 0.86% per patient year respectively. Structural deterioration (calcification and sclerosis) occurred in one patient after AVR and in six patients after MVR, all younger than 60 years of age. Freedom from structural deterioration at five years and 10 years was 100% and 92.9% +/- 6.9% for AVR, and 100% and 76.9% +/- 8.6% for MVR.

CONCLUSIONS

In conclusion, the Carpentier-Edwards aortic valve has a low incidence of valve-related complications at 10 years. Although late results of this valve in the mitral position were excellent in the elderly, leaflet degeneration is still a problem in patients under the age of 60 years.

Squid photoreceptor phospholipase C is stimulated by membrane Gq alpha but not by soluble Gq alpha

Phospholipase C (PLC) was purified from squid retina. Soluble Gq alpha, membrane Gq alpha and G beta gamma were isolated from GTP gamma S-treated and light-illuminated photoreceptor membranes. The membrane Gq alpha stimulated phosphatidyl inositol-phospholipase C (PI-PLC) activity in a dose-dependent manner. Soluble Gq alpha and membrane G beta gamma showed no stimulating effects on PLC. GTP gamma S-binding was found exclusively in membrane fraction, with very little present in the KCl-soluble fraction which contained soluble Gq alpha. These results indicate that light-activated rhodopsin activates PLC through membrane-bound Gq alpha and suggest that the rhodopsin/Gq/PLC cascade might be the pathway of phototransduction in squid photoreceptors.

[Evaluation of surgical procedures based on the types of hypertrophied obstructive cardiomyopathy]

The surgical procedures were reviewed based on the types of hypertrophied obstructive cardiomyopathy in 20 patients. The patients were classified in three groups: (1) Asymmetric septal hypertrophy (ASH), (2) Atypical or diffuse concentric hypertrophy (DIF), (3) Mid ventricular obstructive hypertrophy (MID). Among 11 patients with ASH, the ventricular septal myotomy (My) or the myotomy-myectomy (Mye) were performed in 9 patients and MVR was performed in 2 patients. Among 6 patients with DIF, My or Mye were performed in 4 and MVR was performed in 2. All three patients with MID were treated with MVR. The intraventricular systolic pressure gradient greater than 40 mmHg was still existent postoperatively in one ASH patient on whom Mye was performed and in 3 DIF patients on whom My or Mye were performed. The four patients had III degree mitral regurgitation preoperatively and were successfully treated. The postoperative NYHA functional class became II or less in all patients. For ASH, the My was effective in 9 patients except one earlier patient. For DIF, further consideration of surgical procedure might be required. For MID, a MVR is recommended.

Modified maze procedure for patients with atrial fibrillation undergoing simultaneous open heart surgery

BACKGROUND

Persistent atrial fibrillation (AF) leaves patients symptomatic and at increased risk of thromboembolism even after otherwise successful cardiac surgery.

METHODS AND RESULTS

To treat AF secondary to cardiac lesions requiring surgery, we combined a modified maze procedure in 101 patients simultaneously undergoing valvular procedures (87), repair of congenital anomalies (12), and other procedures (2), including 24 repeat operations. Duration of AF varied from 0.1 to 30 years (average +/- SD, 8.8 +/- 7.0 years); the f-wave voltage ranged from 0 to 0.45 mV (0.15 +/- 0.09 mV); and cardiothoracic ratio varied from 40% to 99% (63 +/- 9%). Aortic cross-clamp time varied from 75 to 229 minutes (138 +/- 31 minutes), with bypass time ranging from 119 to 326 minutes (217 +/- 42 minutes). There were two early deaths (2%), no late deaths, and one episode of transient neurological ischemic attack in follow-up ranging from 1.0 to 3.1 years, for a total of 190 patient-years. Postoperative rhythms were sinus in 83 patients (82%), junctional in 4 (4%), and persistent AF in 14 (14%), each of whom had mitral valve disease. Patients with other underlying pathology had complete recovery of atrial rhythm. A normal-sized A wave was detected in 88% for transtricuspid flow and in 73% for transmitral flow, suggesting concomitant recovery of atrial contraction. Among 36 patients without mechanical valves, 30 (83%) with atrial rhythm and contraction have been taken off anticoagulation therapy, including 10 who are free of all medication.

CONCLUSIONS

The results suggest that the combined approach is safe, effective, and indicated in patients who are judged capable of tolerating the procedure and likely to regain atrial rhythm.

[Results of coronary artery bypass grafting in dialysis patients]

To determine the short- and medium-term results of coronary artery bypass grafting (CABG) in dialysis patients, we analyzed a group of 14 patients with chronic renal failure who underwent CABG between May 1990 and October 1994. Two patients had concomitant valve repair for mitral regurgitation. Hospital mortality was 14% (2 out of 14). These two patients died of ileus due to ischemic colitis and agranulocytosis respectively. There was one late death from stroke. The four significant postoperative complications (morbidity 29%) were composed of two sternal dehiscence, one cardiac tamponade because of bleeding, and one perioperative myocardial infarction. Graft patency rate was 97% (34 out of 35 in 13 patients) within one month. Actuarial survival was 86% at one 1 to 3 years, and 43% at 3 and a half years. This rate is not significantly different from all dialysis patients, but night be better than dialysis patients with coronary artery disease who had not undergone CABG in the previous reports. Left ventricular size is larger in patients who died or who had significant complications in hospital than in patients with uneventful postoperative course. Cardiac arrest time, cardiopulmonary bypass time, chest tube output, and the amount of transfusion might be also related to mortality and morbidity though statistically not significant.

The nitrate reductase gene from a shoyu koji mold, Aspergillus oryzae KBN616

A niaD gene encoding nitrate reductase was isolated from Aspergillus oryzae KBN616 and sequenced. The structural gene comprises 2973 bp and 868 amino acids, which showed a high degree of similarity to nitrate reductases from other filamentous fungi. The coding sequence is interrupted by six introns varying in size from 48 to 98 bp. The intron positions are all conserved among the niaD genes from A. oryzae, Aspergillus nidulans, and Aspergillus niger. A homologous transformation system was developed for an industrial shoyu koji mold, A. oryzae KBN616, based on the nitrate reductase (niaD) of the nitrate assimilation pathway.

[Surgical treatment and long-term results of cardiac myxoma in 38 patients]

Long-term results of thirty-eight patients with cardiac myxoma, who underwent resection at National Cardiovascular Center between May, 1978 and December, 1993, were reviewed focussing on embolism, cerebral complication, tumor recurrence and metastasis. The mean age was 49.6 years (range 0 to 74) in 20 female and 18 male. Overall follow-up were known for 35 of 38 patients (92.1%), and an average of follow-up period was 6.7 years (range 0.5 to 15.9 years). 15 of 38 patients (34.2%) had embolism (brain 10, peripheral artery 4, coronary 1) preoperatively. All patients survived operation and the hospital mortality rate was 0%. Long-term results were almost satisfactory (myxoma related-death in one patients). However, distant metastasis occurred in two patients, and tumor recurrence in one patient irrespective of a presence of preoperative embolism. Cerebral embolism occurred in one patient and cerebral arterial lesins were noticed in five patients postoperatively. Cardiac myxoma has a malignant potentiality and a close follow-up is necessary about recurrence, metastasis and cerebral artery disease.

Phosphatidyl inositol-phospholipase C in squid photoreceptor membrane is activated by stable metarhodopsin via GTP-binding protein, Gq

Phosphatidyl inositol-phospholipase C (PI-PLC) in squid retina was studied by immunoblotting and its activities were determined using [3H]phosphatidyl inositol bisphosphate ([3H]PIP2) as substrate. PI-PLC activity was found mostly in soluble fraction when the retina homogenate was treated with 400 mM KCl, but was associated with rhabdomal membranes under low salt conditions (20 mM Hepes). A protein with apparent molecular mass of 130kD was recognized by an antibody against PLC beta 4/norp A in both 400 mM KCl soluble and rhabdomal membrane fractions. A 42 kD protein recognized by antibody against the C-terminus of Gq alpha was also present in these two fractions. GTP gamma S stimulated only the PI-PLC activity associated with membrane and was magnesium dependent. PI-PLC activity was found to be (i) highly dependent upon calcium concentrations, (ii) enhanced by GTP but not by other nucleotides, and (iii) significantly stimulated by light at lower concentrations of GTP gamma S. The stimulation by light was still observed when irradiated membrane was incubated at 10 degrees C for 10 min and then mixed with GTP gamma S. These results suggest that stable metarhodopsin stimulates a PLC beta 4/norp A-like enzyme via a G-protein, Gq.

[The effects of Ebselen upon post-ischemic functional recovery in rat heart]

The effects of Ebselen (DR-3305) upon cardiac function and CK leakage with or without ischemia reperfusion insults were investigated in this isolated working rat heart study. In order to evaluate the effects of Ebselen upon cardiac function, it was administrated to the isolated rat heart with Langendorff perfusion for 15 min at 100 cmH2O. Cardiac functions such as aortic and coronary flow, heart rate and aortic pressure, before and after Ebselen treatment, were measured and expressed as percent of the control value. The coronary resistance was significantly reduced in 100 nM, 500 nM and 1000 nM of Ebselen pretreatment with dose dependent manner. However pretreatment with 1000 nM of Ebselen significantly decreased cardiac output with significant increase of CK leakage. The myocardial protective effects of Ebselen in the cardioplegia or reperfusate were investigated under conditions of normothermic ischemia. After measuring preischemic cardiac functions, the St. Thomas' Hospital cardioplegic solution was infused for 3 min followed by 35 min of global ischemia at 37 degrees C. Hearts were then aerobically reperfused for 15 min in the Langendorff mode. Subsequently, cardiac function was measured and expressed as percent of the preischemic control value. Ebselen addition to the St. Thomas' cardioplegic solution did not possess any myocardial protective effects, although addition to reperfusate possess the protective abilities at a concentration of 10 nM. From these data, Ebselen, which was one of the free radical scavenger, had the myocardial protective effects if it was added to reperfusate at a concentration of 10 nM.

[A case of aortitis operated twice Bentall's operation due to valve (graft) detachment]

A 40-year-old man had received emergency Bentall's operation due to acute aortic regurgitation (AR) of aortitis in October, 24, 1990. On out patient clinic, the CRP had been kept from 0.5 to 1.5 mg/dl in dose of 10 mg of prednisolone. In the midnight of November, 17, 1992, his condition deteriorated to circulatory shock and echocardiography revealed massive AR due to para-annular graft detachment with large pseudoaneurysm of 50 mm. He was transferred for emergency operation. The composite graft shifted 2-3 cm above the annulus and detached in three quarter of the annulus. Distal anastomosis was also detached in half of anastomosis and coronary anastomosis almost detached. He was operated on modified Bentall's operation employing Piehler's technique and he is now followed in dose of 10 mg of prednisolone. There are some cases of aortitis showing recurrent valve or graft detachment like this case, even if modified Bentall's operation have been done to decrease the mechanical stress to the annulus and the inflammation have been controlled under the dosage of steroid.

[Effects of subcutaneous administration of erythropoietin on autologous blood predonation in open heart surgery: Japanese multicenter double-blinded dose-study]

The effects of subcutaneous administration of recombinant human erythropoietin (EPO) on harvesting autologous blood predonation (ABP) and decreasing homologous blood transfusion (HBT) in open-heart surgery were examined prospectively in 132 patients treated in a 32-institute multicenter study. Single doses of 6000, 12,000, 18,000 and 24,000 unit (IU) of EPO with intravenous iron (40 mg) were administered once a week for 3 weeks with ABP (400 ml/week) before surgery. ABP volume (ml), change of blood hemoglobin level (C-Hb), preoperative net blood hemoglobin increase (delta Hb [g/dl] including ABP, perioperative blood loss (ml), and HBT rate, were as follows; [table: see text] Preoperative reduction of Hb (C-Hb) was less in administration dose of 18,000 IU and 24,000 IU than 6000 IU (p < 0.05). The increase of delta Hb was highest in 18,000 IU and HBT rate was lowest in administration dose of 24,000 IU, however, there was no statistical difference. In conclusion, both 18,000 IU and 24,000 IU of EPO treatment is effective to minimize the progression of anemia according to ABP for open heart surgery.

Prediction of postoperative exercise tolerance after aortic valve replacement

Valve size selection for aortic valve replacement is still a controversial matter, particularly in patients with small aortic annuli. To assess optimal valve size, exercise capacity, as measured by peak oxygen consumption levels, was determined in 39 patients (age range, 18 to 77 years; mean, 56 years) who underwent isolated aortic valve replacement with a St. Jude Medical valve. This assessment was carried out at a mean of 2.2 years post-operatively using ergometer exercise testing. These levels were evaluated as a measure of the percentage of predicted. At rest, there was no significant correlation between the predicted peak oxygen consumption and the pressure gradients across the prostheses, as measured by Doppler ultrasound. In 18 patients with aortic regurgitation, the preoperative dimensions of the left ventricle in end-diastole and end-systole correlated inversely (p < 0.05) with the percentage of predicted peak oxygen consumption. In 21 patients with aortic stenosis, the linear regression line (p < 0.01) was derived from the correlation between the percentage of predicted peak oxygen consumption and the valve area index (geometric valve orifice area/body surface area). We conclude that the preoperative end-systolic and end-diastolic dimensions should be less than 50 mm and 70 mm, respectively, in the setting of aortic regurgitation, and a valve area index, though it proved to be weakly correlated with the percentage of the peak oxygen uptake, should probably be more than 1.5 cm2/m2 in the setting of aortic stenosis to achieve good exercise capacity postoperatively (> 80% of predicted peak oxygen consumption).

Cox maze procedure for chronic atrial fibrillation associated with mitral valve disease

Between April 1992 and October 1993, we combined a modified maze procedure with mitral valve repair (n = 26) or replacement (n = 36) in 62 patients with atrial fibrillation, including 16 patients undergoing reoperation. Associated procedures included aortic valve operation (n = 22), tricuspid annuloplasty (n = 28), atrial plication (n = 10), and others (n = 3). Duration of atrial fibrillation varied from 0.1 to 23 years (average 8.3 +/- 6.4 years), the f-wave voltage ranged from 0 to 0.45 mV (0.16 +/- 0.09 mV), and cardiothoracic ratio varied from 46% to 85% (64% +/- 9%). We modified the maze atriotomies to preserve the sinus node artery and used cryoablation to simplify procedures. Aortic crossclamp time was 142 +/- 25 minutes and cardiopulmonary bypass time 226 +/- 34 minutes. No early or late deaths occurred in a total of 783 patient-months of follow-up. In 52 patients (84%) who regained atrial rhythm, an atrial A-wave was detected in 84% for transtricuspid flow and in 71% for transmitral flow. One patient with sinus rhythm had an episode of transient neurologic ischemia 4 months after mechanical valve implantation. The 10 patients who remained in atrial fibrillation had preoperative fibrillation for a significantly longer time than the rest of the patients with atrial rhythm (14.8 versus 7.2 years p < 0.001) and a larger left atrial dimension (70 versus 58 mm, p < 0.01). Nonetheless, no variable alone could have predicted postoperative rhythm for individual patients. The results suggest that the maze procedure is safe and effective and therefore should be considered for patients with chronic atrial fibrillation undergoing mitral valve operations.