Combination of neuroendoscopic hematoma evacuation and endovascular coil embolization for a ruptured anterior choroidal artery aneurysm in patients with moyamoya disease: illustrative cases

BACKGROUND

The treatment strategy for hemorrhagic moyamoya disease (MMD) due to a ruptured aneurysm at the distal portion of the anterior choroidal artery remains controversial. The authors successfully treated the ruptured aneurysm with neuroendoscopic hematoma evacuation, followed by endovascular coil embolization.

OBSERVATIONS

The authors encountered two patients with massive hemorrhagic MMD whose MMD had already been diagnosed and who had a periventricular anastomosis due to a ruptured aneurysm of the distal portion of the anterior choroidal artery involving the periventricular anastomosis. In both cases, neuroendoscopic hematoma evacuation was performed for hemorrhagic MMD in the acute phase, followed by endovascular coil embolization of the ruptured aneurysm in the chronic phase. In both endovascular treatments, the patient's condition was stabilized by hematoma evacuation, allowing a detailed preoperative evaluation of the anatomical findings of the vessel and functional findings of intraoperative neurophysiological monitoring using continuous monitoring of motor evoked potentials to preserve motor function.

LESSONS

Combination therapy can be useful for hemorrhagic MMD in patients with diagnosed MMD with a periventricular anastomosis. Additionally, a preoperative understanding of the vascular construction and intraoperative neurophysiological monitoring will aid in the successful coil embolization of aneurysms at the distal portion of the anterior choroidal artery with hemorrhagic MMD.

Bilateral Trans-Sulcal and Interhemispheric Approaches for Butterfly Glioblastoma: 2-Dimensional Operative Video

Butterfly glioblastoma (bGB) poses significant surgical challenges, yet recent findings have highlighted the potential of surgical decompression in extending patient survival.1-10 The selection of a surgical strategy for bGB varies across studies. Generally, the side with a larger tumor volume is a preferred approach route, and the nondominant hemisphere is preferred when both tumors are similar in size. The contralateral tumor is removed via the resection cavity of the ipsilateral side,11 with successful utilization of endoscopic-assisted techniques.8 In the case of deep-seated bGB covered with a thick intact brain, accessing the tumor requires creating an invasive corridor, therefore minimizing the damage to the intact brain is ideal. A man in his 70s presented the new-onset seizure. Preoperatively, the patient exhibited a Karnofsky performance status of 50% without any motor deficits, and magnetic resonance imaging demonstrated a deep-seated anterior bGB with a larger tumor volume on the left dominant side. Imaging showed the tumor located just beneath the bilateral superior frontal sulci. Therefore we used these sulci to access the tumor with the minimum cut of the intact brain while preserving the frontal aslant tracts and used bilateral interhemispheric approaches to protect the cingulate bundles. We conducted the same technique for another deep-seated anterior bGB case, both resulting in postoperative Karnofsky performance status improvements (Video 1). Tailoring the surgical approach to the unique characteristics of each bGB case is important. The patients consented to the procedure and the publication of their images.

Anatomical and neurophysiological localization of the leg motor area at the medial central sulcus

OBJECTIVE

The exact location of the leg motor area is still in debate due to the lack of landmarks such as 'precentral knob' in the medial cortex. This study tried to identify the leg motor area based on intraoperative neurophysiological data and neuroimaging techniques.

METHODS

Intraoperative data of somatosensory evoked potential (SEP) elicited by tibial nerve stimulation and motor evoked potential (MEP) of the leg muscles induced by direct cortical stimulation were recorded using subdural electrodes placed in the medial cortex. We displayed the neurophysiological data on the individual MR images and the MNI52.

RESULTS

Definite N40-P40 phase reversal was observed with the shallow grooves in the medial cortex in 5 cases. Leg MEP was successfully obtained in all 12 cases preserving the leg motor function. Superimposed SEP and leg MEP data on the MNI152 indicated the leg motor area was predominantly located in the posterior two-thirds between the vertical lines passing through the anterior commissure and the posterior commissure (VCP).

CONCLUSIONS

Our study revealed the location of the leg motor area and the presence of the 'medial central sulcus' in the medial cortex.

SIGNIFICANCE

The VCP can be useful landmark to identify the sensorimotor border in the medial cortex.

Endoscope-integrated indocyanine green video angiography and the detection of the fragile periventricular collaterals associated with moyamoya disease: illustrative cases

BACKGROUND

Hemorrhagic moyamoya disease (MMD) and the fragile periventricular collaterals are known to have a causal relationship. Digital subtraction angiography and magnetic resonance angiography have shown the presence of fragile periventricular moyamoya vessels. However, dynamic fragile periventricular moyamoya vessels have never been observed under direct vision.

OBSERVATIONS

The authors treated two patients with hemorrhagic MMD: a 42-year-old man with intraventricular hemorrhage and a 47-year-old woman with intracerebral hemorrhage. Endoscope-integrated indocyanine green video angiography (EICG angiography) could visualize the dynamic fragile periventricular collaterals. In particular, EICG angiography enabled visualization of invisible moyamoya vessels buried in the subependyma and characterization of the blood flow in the moyamoya vessels located inside the lateral ventricles and hematoma cavity.

LESSONS

EICG angiography can confirm the fragile periventricular collaterals associated with MMD by direct visualization. The high spatial resolution and real-time imaging can help to avoid accidental hemorrhage in and after evacuation of hemorrhage in patients with MMD.

Technique of Duplex Scanning for Selection of Optimal Peripheral Anastomosis Site for Distal Bypass

Introduction

Selection of the optimal anastomosis site is essential for obtaining good results from distal bypass. Herein, a unique, precise technique that uses pre-operative duplex scanning for selecting this site is presented.

Technical summary

Before distal bypass surgery, duplex scanning is performed to assess patency and flow. Use of the venous preset mode and controlling the slant function allows visualisation of colour Doppler flow inside the arteries, thus enabling selection of the best segment for anastomosis.

Conclusion

Use of duplex scanning in the appropriate mode consistently enables selection of the best anastomosis site for distal bypass, even when there is heavy calcification.

Impact of reduced endogenous anti-coagulation protein activity on vascular events of peripheral arterial disease

AIM

Aim of the study is to elucidate the prevalence and the prognosis of patients with peripheral arterial disease (PAD) who have reduced endogenous anti-coagulation protein activity.

METHODS

Ninety six patients with PAD were studied, including 45 patients with intermittent claudication and 51 with critical limb ischemia. Among them 65 patients underwent peripheral artery bypass grafting. Venous blood samples were obtained and plasma activity level of Protein C (PC), Protein S (PS), Plasminogen (PLG), Antithrombin (AT) were measured. Based on the patients' clinical database the prevalence and clinical relevance was studied.

RESULTS

In our PAD patients PC activity is reduced in 18.8%, PS activity is reduced in 16.7%, PLG activity was reduced in 15.6% and AT activity was reduced in 24.0%. The incidence of AT activity deficiency was significantly higher in patients with critical limb ischemia than patients with claudication (P<0.01). After revascularization, arterial event free rate of patients with PC or PS activity deficiency and those with PLG deficiency were significantly lower than those without during the mean follow-up period of 26+/-31 months. The incidence of thromboembolic episodes and leg amputation rate were significantly worse in patients with PC deficiency.

CONCLUSIONS

PAD patients with reduced endogenous anti-coagulation proteins show worse prognosis than those without. Surgeons must be aware of it to improve the outcome of arterial revascularization.

Preliminary study of autologous blood predonation in pediatric open-heart surgery impact of advance infusion of recombinant human erythropoietin

We applied an autologous blood predonation protocol using recombinant human erythropoietin in pediatric open-heart surgery. The study included 69 children weighing 8 kg or more. Twice before operation, 8 ml/kg of blood was taken. At each donation, 100 (group 1; n = 20), 200 (group 2; n = 11), or 300 (group 3; n = 13) units/kg of erythropoietin was given subcutaneously. In group 4 (n = 25), 300 units/kg of erythropoietin was given 1 week prior to the first donation, followed by 300 units/kg given at each donation. No harmful events occurred during the donation period. During the donation period, the patients' hematocrit decreased but the hematocrit 1 day after the operation remained at 32.1 +/- 0.6% and was 33.3 +/- 0.6% 2 weeks later. The decrease in hematocrit was minimal in group 4 (39.0 +/- 0.6% before donation to 37.5 +/- 0.5% before operation) compared with that of the other three groups. Among those who completed the protocol, 58 patients (93.5%) were discharged without homologous blood transfusion. We consider our protocol of autologous blood predonation using erythropoietin to be safe and effective for avoiding homologous blood transfusion in pediatric patients. The early infusion of erythropoietin prior to the first donation minimizes the decrease in hematocrit level before operation.

Plasma hepatocyte growth factor levels after open heart surgery for congenital heart disease

BACKGROUND

Hepatocyte growth factor (HGF) is a polypeptide which acts protectively against endothelial cell dysfunction. A high plasma level of HGF is shown when the endothelium is injured. We measured plasma HGF levels during and after open heart operations for congenital heart disease, to elucidate its involvement with endothelial cell injury.

METHODS

EXPERIMENTAL DESIGN

prospective study.

SETTING

perioperative setting.

PATIENTS

18 children electively operated upon for congenital heart disease using CPB.

RESULTS

Plasma HGF levels (ng/ml) before cardiopulmonary bypass (CPB) were 0.36+/-0.07 in 10 children (S-group) who were older and with simpler diseases, and 0.48+/-0.12 in 8 children (C-group) who were younger and with relatively complex diseases. HGF levels significantly increased after CPB, and gradually decreased thereafter. Plasma HGF levels 3 and 6 hours after CPB were significantly greater in the C-group than in the S-group (1.13+/-0.12 vs 1.68+/-0.1 6 3 hours after, and 1.09+/-0.19 vs 2.35+/-0,43 6 hours after; p<0.05 for both). There were significant positive correlations between HGF levels 6 hours after CPB and the duration of the CPB, the aortic crossclamping time, and plasma thrombomodulin levels just after CPB in all patients (p<0.05 for all).

CONCLUSIONS

This data suggests that increased HGF levels are associated with endothelial cell injury induced by CPB, and that the increases are much greater in younger patients with complex anomalies.

Right atrial rupture in blunt chest trauma

The mortality rate from cardiac rupture by blunt chest injury is high. Here, we report a case of 27-year-old male who suffered a right atrial rupture by blunt chest injury and was successfully treated. The hemodynamics were stabilized by pericardiocentesis with a 5F Pigtail catheter for cardiac tamponade and rapid fluid transfusion. Then the right atrial rupture was repaired without a cardiopulmonary bypass. The postoperative course was uneventful, and the patient was discharged on the 14th postoperative day.

Local anesthetic inhibition of voltage-activated potassium currents in rat dorsal root ganglion neurons

BACKGROUND

Local anesthetic actions on the K+ channels of dorsal root ganglion (DRG) and dorsal horn neurons may modulate sensory blockade during neuraxial anesthesia. In dorsal horn neurons, local anesthetics are known to inhibit transient but not sustained K+ currents. The authors characterized the effects of local anesthetics on K+ currents of isolated DRG neurons.

METHODS

The effects of lidocaine, bupivacaine, and tetracaine on K+ currents in isolated rat DRG neurons were measured with use of a whole cell patch clamp method. The currents measured were fast-inactivating transient current (I(Af)), slow-inactivating transient current (I(As)), and noninactivating sustained current (I(Kn)).

RESULTS

One group of cells (type 1) expressed I(Af) and I(Kn). The other group (type 2) expressed I(As) and I(Kn). The diameter of type 2 cells was smaller than that of type 1 cells. Lidocaine and bupivacaine inhibited all three K+ currents. Tetracaine inhibited I(As) and I(Kn) but not I(Af) For bupivacaine, the concentration for half-maximal inhibition (IC50) of I(Kn) in type 2 cells was lower than that for I(Kn) in type 1 cells (57 vs. 121 microM). Similar results were obtained for tetracaine (0.6 vs. 1.9 mM) and for lidocaine (2.2 vs. 5.1 mM).

CONCLUSIONS

Local anesthetics inhibited both transient and sustained K+ currents in DRG neurons. Because K+ current inhibition is known to potentiate local anesthetic-induced impulse inhibition, the lower IC50 for I(Kn) of small type 2 cells may reflect preferential inhibition of impulses in nociceptive neurons. The overall modulatory actions of local anesthetics probably are determined by their differential effects on presynaptic (DRG) and postsynaptic (dorsal horn neurons) K+ currents.

Midterm results after ventricular septation for double-inlet left ventricle in early infancy

We performed ventricular septation for a 40-day-old boy with double-inlet left ventricle and discordant ventriculoarterial connection but without pulmonary stenosis. Postoperative cardiac function is satisfactory, with no evidence of pulmonary hypertension or subaortic stenosis. Nine years after the operation, the patient has an active life, is free from symptoms, and requires no medication. He may be the first patient to survive ventricular septation for double-inlet left ventricle in early infancy.

Nitric oxide synthase expression in lungs of pulmonary hypertensive patients with heart disease

Since little is known about the contribution of endothelial nitric oxide synthase (e-NOS) to the mechanism of pulmonary vasospasm and the development of pulmonary vascular occlusive disease, we elucidate how e-NOS is expressed in lung biopsy specimens obtained from operative patients with pulmonary hypertension. Lung biopsy specimens were obtained from 17 patients who underwent open-heart operations for various heart diseases. A piece of normal lung specimen was also obtained from the resected lungs of three lung cancer patients as a control. e-NOS expression was visualized with a monoclonal antibody against e-NOS, and the level of expression was partially quantified. Significantly high levels of e-NOS expression were seen in adult patients, whose preoperative mean pulmonary arterial pressures were greater than 20 mm Hg. In contrast, e-NOS expression in pediatric patients with the same levels of mean pulmonary arterial pressure was the same as that in the controls and in low pulmonary arterial pressure. There was a statistically significant positive correlation between the level of e-NOS expression and Heath--Edwards grading. These data suggest that the e-NOS expression in lung tissue is induced when pulmonary vascular obstructive diseases progress.

Autologous blood donation with recombinant human erythropoietin for abdominal aortic aneurysm surgery

We evaluated the efficacy of autologous blood donation using recombinant human erythropoietin for elective abdominal aortic aneurysm (AAA) surgery regarding postoperative recovery. Twenty-five AAA patients who completed surgery without receiving a homologous blood transfusion were divided into two groups, consisting of a control group (n = 12) who did not bank any autologous blood, and a donation group (n = 13) who did bank more than 800 ml of autologous blood with the use of erythropoietin. The hematocrit (Ht) level of the control group decreased from 41.1% +/- 1.2% before the operation to 36.2% +/- 0.9% just afterwards (P > 0.01). In the donation group, however, the Ht did not change significantly during either the donation period or the perioperative period. The postoperative period before oral food intake and natural defecation were both significantly shorter in the donation group than in the control group. The first day of mobilization was also earlier in the donation group. In conclusion, autologous blood donation using erythropoietin for AAA surgery is therefore considered to promote the early recovery of patients.

Ductal aneurysm of adult patients

A ductal aneurysm is very rarely diagnosed in adults. We experienced 2 cases of adult ductal aneurysm. Both cases developed hoarseness and computed tomographic scanning demonstrated a typical 'triple star sign' at the aortopulmonary window level. They underwent surgical repair with successful results. During the same period, we experienced 38 operations for true thoracic aneurysm. The ductus origin was found in 5.2% of these patients. The ductal aneurysm may no longer be considered a 'rare' vascular disease with more careful diagnostic procedure.

[A case report of successful mitral valve replacement for congenital mitral stenosis associated with coarctation of the aorta and ventricular septal defect]

A 5-month-old infant with coarctation of the aorta, ventricular septal defect and mitral stenosis known as "Shone's anomaly" is presented. He underwent the repair of coarctation of the aorta by means of the extended aortic arch anastomosis and banding of the pulmonary trunk at 1 month of age and the patch closure of ventricular septal defect and debanding of the pulmonary trunk at 3 months of age in our institution. About 2 months after second surgery, he had been admitted to our institution due to developing tachypnea and he needed the support of mechanical ventilation. The chest X-ray showed pulmonary congestion and the echocardiography revealed only one papillary muscle of mitral valve and pressure gradient about 30 mmHg through mitral valve. Mitral stenosis due to parachute mitral valve was suspected and he was subjected to an emergent surgery. Initially we performed mitral valve repair for parachute mitral valve but echocardiography during the surgery revealed moderate grade of mitral regurgitation and a hemodynamics was not satisfactory. Eventually mitral valve replacement was successfully done with Carbo-Medics mechanical valve (19 mm in diameter) in the position of left atrial wall because his mitral annulus was so small as 10 mm in diameter. The postoperative course was uneventful and the patient has been doing well.

Interaction of bupivacaine and tetracaine with the sarcoplasmic reticulum Ca2+ release channel of skeletal and cardiac muscles

BACKGROUND

Although various local anesthetics can cause histologic damage to skeletal muscle when injected intramuscularly, bupivacaine appears to have an exceptionally high rate of myotoxicity. Research has suggested that an effect of bupivacaine on sarcoplasmic reticulum Ca2+ release is involved in its myotoxicity, but direct evidence is lacking. Furthermore, it is not known whether the toxicity depends on the unique chemical characteristics of bupivacaine and whether the toxicity is found only in skeletal muscle.

METHODS

The authors studied the effects of bupivacaine and the similarly lipid-soluble local anesthetic, tetracaine, on the Ca2+ release channel-ryanodine receptor of sarcoplasmic reticulum in swine skeletal and cardiac muscle. [3H]Ryanodine binding was used to measure the activity of the Ca2+ release channel-ryanodine receptors in microsomes of both muscles.

RESULTS

Bupivacaine enhanced (by two times at 5 mM) and inhibited (66% inhibition at 10 mM) [3H]ryanodine binding to skeletal muscle microsomes. In contrast, only inhibitory effects were observed with cardiac microsomes (about 3 mM for half-maximal inhibition). Tetracaine, which inhibits [3H]ryanodine binding to skeletal muscle microsomes, also inhibited [3H]ryanodine binding to cardiac muscle microsomes (half-maximal inhibition at 99 microM).

CONCLUSIONS

Bupivacaine's ability to enhance Ca2+ release channel-ryanodine receptor activity of skeletal muscle sarcoplasmic reticulum most likely contributes to the myotoxicity of this local anesthetic. Thus, the pronounced myotoxicity of bupivacaine may be the result of this specific effect on Ca2+ release channel-ryanodine receptor superimposed on a nonspecific action on lipid bilayers to increase the Ca2+ permeability of sarcoplasmic reticulum membranes, an effect shared by all local anesthetics. The specific action of tetracaine to inhibit Ca2+ release channel-ryanodine receptor activity may in part counterbalance the nonspecific action, resulting in moderate myotoxicity.

Tetralogy of Fallot with levoatrial cardinal vein

A levoatrial cardinal vein is a rare congenital anomaly of the systemic veins. It is frequently associated with left-side obstructive anomalies. We report a case of tetralogy of Fallot with a levoatrial cardinal vein. The innominate vein was absent and two left upper pulmonary veins connected to this vein. There were no left-side obstructive anomalies.

[Lower mid-line skin incision and minimal sternotomy in pediatric open heart surgery--an alternative cosmetic approach]

Full median sternotomy has been the standard approach for open heart surgery. However, it leaves an unsightly surgical scar. We therefore designed a lower mid-line skin incision and minimal sternotomy approach as a cosmetic alternative. Since February 1993, 78 pediatric patients with congenital heart disease have undergone this open heart surgery procedure. Their ages ranged from 1 month to 13 years (median: 2 years and 7 months) and body weights ranged from 2.4 to 43 kg (median: 11.5 kg). Thirty-one patients had atrial septal defect, 34 perimembranous ventricular septal defect, 9 subpulmonary ventricular septal defect, and 4 other cardiac anomalies. All cannulations for cardiopulmonary bypass could be performed through this approach. No patients required conversion to standard median sternotomy and no peri- or postoperative complications related to this approach, such as injury to the great artery and vein, air embolism, or sternal deherence, were noted. This approach is technically easy and an excellent cosmetic approach in pediatric open heart surgery.

Successful operative treatment for acute triple-barreled aortic dissection in a patient with Marfan's syndrome: report of a case

Triple-barreled aortic dissection is a rare form of aortic dissection associated with high mortality. We report herein the case of a 41-year-old woman with Marfan's syndrome who developed acute triple-barreled aortic dissection from a Stanford type B dissecting aneurysm. Successful graft replacement of the proximal third of the descending thoracic aorta was subsequently performed. To the best of our knowledge, this is the first case of successful operative treatment for an acute triple-barreled aortic dissection ever to be reported.

Plasma adrenomedullin level after cardiopulmonary bypass

Adrenomedullin is an intrinsic vasodilator which is metabolized mainly in the pulmonary circulation. We measured plasma levels of adrenomedullin in children with congenital cyanotic heart disease (CY group, n = 6), children with high pulmonary blood flow due to congenital heart disease (PH group, n = 8), and in adults with mitral valve disease (MV group, n = 7) before and 3 h after cardiopulmonary bypass (CPB). Before CPB, the adrenomedullin level was the highest in the MV group, possibly due to chronic heart failure. Three hours after CPB, the plasma adrenomedullin level (pg/ml) increased to 1712.7 +/- 498.4 in the CY group, 167.6 +/- 26.4 in the PH group, and 1404.3 +/- 313.7 in the MV group, the level in the PH group being significantly lower than the rest. In the PH group, there was statistically significant negative correlation between the mean pulmonary arterial pressure at the preoperative catheter study, and the adrenomedullin level 3 h after CPB. These results illustrate that the adrenomedullin level increased after CPB, but that the increase was less marked in the PH group, implying that where the pulmonary vasculature was damaged most, this results in increased vasoconstriction.

[Combined coronary artery bypass with right nephrectomy in a patient with left main lesion, calcified ascending aorta, pelvic carcinoma and liver cirrhosis]

A 66-year-old female had ischemic heart disease due to left main lesion complicated with calcified ascending aorta, right pelvic carcinoma and liver cirrhosis. The combined operations with coronary artery bypass by left internal thoracic artery under the hypothermic ventricular fibrillation with cardiopulmonary bypass and right nephrectomy were performed successfully. Postoperatively Treadmill exercise test and scintigram revealed no ischemihc change. She is doing well. The aortocoronary bypass to left anterior descending artery using a left internal thoracic artery under hypothermic ventricular fibrillation with cardiopulmonary bypass might be one of surgical options for high risk patient.

[Closed Brock operation for an infant case of double outlet right ventricle with pulmonary atresia]

One-month-old boy with double outlet right ventricle and pulmonary atresia was referred to us for surgical treatment. As he had a membranous obstruction of the pulmonary artery we chose closed Brock operation as an initial procedure. A 6.5 mm in diameter of Trocar was used to open the atretic valve. Postoperative course was uneventful and his oxygen saturation was maintained satisfactory. At the age of one year and nine months he underwent corrective surgery. The pulmonary valve was widely opened enough to perform the right ventricular outflow tract reconstruction with valvotomy and outflow patch. The boy got well and was followed in the outpatient clinic. Double outlet right ventricle with membranous pulmonary atresia is a rare combination and closed Brock operation is shown to be one of the most effective procedure for this type of anomaly.

[The long-term result of an adult case of transposition of the great arteries corrected with Rastelli operation at the age of thirty-two years]

A 32-year-old woman with transposition of the great arteries was referred to us for corrective surgery. She had severe cyanosis, dyspnea, and hemoptysis. The cardiac catheter study and echocardiography revealed that she had transposition of the great arteries, associated with atrial septal defect, ventricular septal defect, patent ductus arteriosus, and pulmonary stenosis. Rastelli operation was performed using equine pericardial roll with three valves made from autologous pericardium. After the operation she gave birth to two children without any symptom. Ventricular tachycardia occurred several times but was controlled by the drug. Eight years after the operation she underwent catheter study. Although the right ventricular pressure was 80 mmHg and the pressure gradient through the conduit was 38 mmHg, her general clinical condition was fairly good. We think the late postoperative result of this patient is satisfactory as an adult case of transposition of the great arteries.

Surgical treatment of a cardiac papillary fibroelastoma developing from the chordae of the tricuspid valve: report of a case

Papillary fibroelastoma is a rare, benign cardiac tumor that can cause multiple emboli. We report herein a case of papillary fibroelastoma developing from the chordae of the tricuspid valve which was detected by echocardiography and confirmed by surgical resection. To our knowledge, this is only the fifth documented case of a tricuspid valve papillary fibroelastoma detected by echocardiography in a living patient.

[Evaluation of the growth of a new pulmonary trunk after the reconstruction of right ventricular outflow tract without using an external conduit]

To evaluate the growth of a pulmonary trunk reconstructed without an extracardiac conduit, the hemodynamics and diameter of a new pulmonary trunk were measured in 5 patients from the right ventriculogram and MRI at postoperative follow-up periods. There were tetralogy of Fallot with pulmonary atresia in two patients, tetralogy of Fallot with single coronary in one, truncus arteriosus type I in one and transposition of the great arteries with ventricular septal defect and pulmonary stenosis in one. The age at operation ranged from 26 days to 4.5 years. The posterior wall continuity of the right ventricle and pulmonary artery was established by the direct pulmonary-right ventricular anastomosis in three patients and by the interposition of the left atrial appendage in two. Postoperative follow-up periods ranged from 2 years and 6 months to 3 years and 10 months (median: 2 years and 11 months). In four of them, the postoperative right ventricular to aortic or left ventricular systolic pressure ratios were less than 0.4 without any significant systolic pressure gradients between pulmonary artery and right ventricle. In these four patients, the diameters of the reconstructed pulmonary trunks grew from 10-18 mm to 18-21 mm postoperatively. These diameters were more than 100% of normal values. In the remaining patient with tetralogy of Fallot and single coronary artery, the obstruction of the new pulmonary trunk by a bulged left atrial appendage, which was used as the posterior wall, was observed on the right ventricular outflow tract reconstruction without an extracardiac conduit has growth potential in the future.

The protective effect of a leucocyte removal filter on the lung in open-heart surgery for ventricular septal defect

We elucidated the protective effect of a leucocyte removal filter on cardiopulmonary bypass (CPB)-induced lung dysfunction during open-heart surgery for ventricular septal defect (VSD). Forty-six VSD patients were divided into two groups: (a) a control group of 22 patients in whom the banked blood was used to prime the CPB circuit, and (b) a leucocyte removal group of 24 patients in whom a leucocyte removal filter was used for priming and every supplement of banked blood during and after the operation. The respiratory index immediately after the CPB was significantly lower in the leucocyte removal group than in the control group (2.23 +/- 0.22 vs 3.90 +/- 0.68; p < 0.05). The duration of stay in the intensive care unit was significantly shorter in the leucocyte removal group (3.0 +/- 0.4 vs 4.1 +/- 0.4 days; p < 0.05). These data suggest that the use of a leucocyte removal filter for blood added to the CPB prime or administered after CPB may have protective effects on lung function after open heart surgery for VSD patients.

Surgical strategy for doubly committed subarterial ventricular septal defect with aortic cusp prolapse

BACKGROUND

Many surgeons recommend early repair of doubly committed subarterial ventricular septal defect regardless of the clinical symptoms. We reviewed our patients of this anomaly with aortic cusp prolapse to justify this strategy.

METHODS

We reviewed the preoperative and postoperative records of 27 patients with doubly committed subarterial ventricular septal defect and aortic cusp prolapse. The patients' ages ranged from 2 months to 11 years (median, 4.6 years).

RESULTS

During the preoperative observation period, aortic regurgitation (AR) developed in 65% of the patients. In the 8 patients without AR before the operation, AR did not develop after the operation, whereas AR persisted in 12 (63%) of the 19 patients with preoperative AR. To identify the risk factors for persistent AR after the operation we analyzed the data for the patients with preoperative AR in the persistent AR group (n = 12) and eliminated AR group (n = 7) and found a longer period from the onset of AR to the operation in the persistent AR group (32.1 +/- 10.1 versus 5.6 +/- 1.9 months; p = 0.014). During the follow-up period 10 of the 17 patients with mild AR before the operation showed persistent AR in the postoperative period, but it did not progress.

CONCLUSIONS

We conclude that early surgical repair with a minimum observation period is essential for prevention of residual AR. Even if a tiny AR is detected preoperatively, the patient should be surgically treated immediately.

Lack of inhibition by inhalational anesthetics of myocardial contraction dependent on intracellular sodium activity

BACKGROUND

When cardiac muscle is stimulated at a high frequency after rest, the peak force increases rapidly at first and then slowly. The slow phase reflects Ca2+ accumulation dependent on an increase in intracellular Na+ activity. The positive inotropic effect of high concentrations of cardiac glycosides also involves Ca2+ accumulation dependent on an increase in intracellular Na+ activity. The effect of isoflurane on the component of myocardial contraction dependent on an increase in intracellular Na+ activity is not well understood.

METHODS

The isometric force of rabbit papillary muscle contractions was measured. The authors studied the effects of isoflurane on the force increase that occurs when the muscles are stimulated after a rest and on the force increase induced by ouabain.

RESULTS

Isoflurane (1.5%, 2.4%) had no statistically significant effect on the magnitude of the slow phase of force increase when the muscles were stimulated at 2 Hz after a rest. Isoflurane (1.5%) did not decrease the magnitude of force increase induced by ouabain (1 microM).

CONCLUSIONS

Isoflurane has little effect on myocardial contractions that depend on Ca2+ accumulation after an increase in intracellular Na+ activity. This may partly account for the smaller cardiac depressant effect of isoflurane observed at high frequencies rather than at low frequencies. The results of the present study and an earlier study with halothane suggest that the lack of inhibition of contractions dependent on Ca2+ accumulation after an increase in intracellular Na+ activity may be a common property of inhalational anesthetics.

Operative technique for persistent left superior vena cava draining into the left atrium

We applied a surgical method with an inverted flap of the left atrial appendage to construct an internal conduit in a 4-year-old girl with a persistent left superior vena cava draining into the left atrium associated with an atrial septal defect. The remaining defect of the septum was closed with autologous pericardium. The short-term result is satisfactory, although the long-term result remains to be ascertained.

An unusual variation of left ventricular-right atrial communication

We herein present a 5-month-old boy with an infravalvular-type left ventricular-right atrial communication without an abnormal tricuspid valve leaflet. The thick chorda of the anterior tricuspid leaflet was inserted into the upper edge of the ventricular septal defect which was placed just under the commissure. The jet from the septal defect pushed this thick chorda and opened the commissure, which thus caused the abnormal pathway from the left ventricle to the right atrium. This mechanism of left ventricular-right atrial communication has not yet been reported elsewhere.

Thrombomodulin and angiotensin-converting enzyme activity during pediatric open heart operations

BACKGROUND

Thrombomodulin and angiotensin-converting enzyme are endothelial glycoproteins. The metabolism of these substances is altered when endothelial cells are damaged.

METHODS

Serum thrombomodulin level was assayed in 56 children and angiotensin-converting enzyme activity determined in 27 children with congenital heart disease before, during, and after open heart operations.

RESULTS

The thrombomodulin level was significantly higher in children with a high pulmonary blood flow who had pulmonary hypertension than in those with a normal pressure (p < 0.01), and although all patients showed an increase in serum thrombomodulin after coming off cardiopulmonary bypass, the increase was greater in those with preoperative pulmonary hypertension (p < 0.05). Serum angiotensin-converting enzyme activity was normal preoperatively in all children, irrespective of pulmonary arterial pressure, and decreased in all after coming off cardiopulmonary bypass but decreased to a significantly greater extent in those who had pulmonary hypertension preoperatively (p < 0.05).

CONCLUSIONS

These findings are compatible with the presence of pulmonary endothelial cell injury and dysfunction before intracardiac repair, which is exacerbated by cardiopulmonary bypass.

[Pulmonary artery banding using expanded polytetrafluoroethylene suture]

Pulmonary artery banding (PAB) is essential for infants of complicated cardiac anomaly without pulmonary stenosis, especially those who require future Fontan type correction. In order to avoid pulmonary artery branch stenosis or uneven growth we utilize expanded polytetrafluoroethylene (E-PTFE) suture (Gore-Tex suture, CV-0) as a banding material. We performed three PABs (two newborns and one infant) with this suture. All children were doing well after the banding and no one revealed residual pulmonary hypertension or pulmonary artery distortion in the postoperative catheter study. One patient successfully underwent total cavopulmonary connection eight months after PAB. We believe E-PTFE suture is an advantageous material of PAB for newborns and young infants.

Procaine enhancement of the rapid cooling contracture and inhibition of the decay of potentiated state in rabbit papillary muscle

We tested the possibility that inhibition of Ca2+ release from the sarcoplasmic reticulum decreases the transsarcolemmal Ca2+ efflux and results in an increased sarcoplasmic reticulum Ca2+ content. We used procaine to inhibit sarcoplasmic reticulum Ca2+ release in rabbit papillary muscles. Rapid cooling-induced contractures were used as an index of sarcoplasmic reticulum Ca2+ content. Decay of potentiated state was measured to study whether the transsarcolemmal Ca2+ efflux is decreased in the presence of procaine. Procaine (0.5, 1.0 mM) inhibited contractions elicited by electrical stimulation and enhanced the rapid cooling-induced contracture. The initial decay of potentiated state that occurs when the muscle was stimulated at a low frequency was slowed in the presence of procaine. These results suggest that procaine inhibition of Ca(2+)-induced release of sarcoplasmic reticulum Ca2+ decreases the transsarcolemmal Ca2+ efflux relative to the influx, resulting in an increased sarcoplasmic reticulum Ca2+ content.

Maturation of the contractile response and its endothelial modulation in newborn porcine intrapulmonary arteries

Pulmonary vascular reactivity is thought to be greater in the newborn than adult lung. To determine the influence of the endothelium on smooth muscle cell contractility, responses of rings of isolated intrapulmonary arteries were studied from pigs at birth aged < 2 h, 2 d, 3 d, and 10 d (n = 4 per age group) and from eight adult animals. At birth, the response to KCl (25 mM) and prostaglandin F2 alpha (PGF2 alpha) (3 microM) but not histamine (0.1 mM) was greater in rings with endothelium (E+) than without (E-). The response to PGF2 alpha decreased between birth and 3 d by which time the contraction was less in E+ rings than E-, but L-nitro monomethyl arginine augmented contraction at all ages. In the immature piglets, the response to phenylephrine was less in E+ rings than E-, an effect which was reversed by L-N omega-nitro-L-arginine methyl ester. The response to all contractile agonists increased between 10 d and adulthood. The concentration of plasma endothelin-1 was determined in all animals by RIA and was higher at birth than at 3 d or later. In summary, 1) at birth, endothelium enhanced contractility, when plasma endothelin was greatest, but released NO in the presence of phenylephrine and PGF2 alpha; 2) contractile response to all agonists was small at birth; and 3) a complex interaction existed between the contractile agonist and the effect of endothelial maturation.(ABSTRACT TRUNCATED AT 250 WORDS)

Donor lung preservation: effect of cold preservation fluids on cultured pulmonary endothelial cells

Pulmonary arterial (PA) endothelial cell morphology changes during cold preservation. In the present study, the efficacy of University of Wisconsin solution (UW), UW solution without colloid (modified UW), Euro-Collins (EC), Marshall's solution (MS), and medium 199 + 10% fetal calf serum [culture medium (CM)] in maintaining and regaining the cytoskeleton of cultured porcine PA endothelial cells kept at 4 degrees C and then rewarmed was compared. Features studied were actin, microtubules, vinculin, and talin, using immunofluorescence, sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and immunoblotting; permeability of the cell sheet; wound healing; and phagocytic capacity. When cooled, microtubules depolymerized in all fluids but EC and MS reduced depolymerization of actin. Permeability decreased at 4 degrees C (P < 0.05), and wound healing and phagocytosis ceased. When rewarmed after EC, UW, and CM preservation, wound healing and phagocytosis started within 15 min and proceeded normally. Permeability returned to normal but was excessive following UW preservation. Microtubule repolymerization was fastest following UW preservation, and actin filament repolymerization was fastest after EC preservation. Thus the type of preservation fluid used influenced the rate of loss and recovery of specific cytoskeletal components, with EC giving the fastest structural and functional recovery.

Effect of thiopental on Ca2+ release from sarcoplasmic reticulum in intact myocardium

BACKGROUND

While thiopental is known to inhibit the myocardial transsarcolemmal influx of Ca2+, the effect of thiopental on sarcoplasmic reticular Ca2+ release has not been characterized.

METHODS

Isolated papillary muscles of rabbits were used. We measured postrest contractions to assess the Ca2+ release by sarcoplasmic reticulum in response to electrical stimulation. Contractures induced by rapid cooling were used as an index of Ca2+ content of sarcoplasmic reticulum. The effect of thiopental on the availability of extracellularly derived Ca2+ was evaluated from measurements of contractions at 0.1 Hz in the presence of 1 microM ryanodine.

RESULTS

Thiopental sodium (10, 20, and 30 mg/l; 38, 76, and 113 microM) inhibited the postrest contraction but not the contracture induced by rapid cooling. In the presence ryanodine, thiopental inhibited the postrest contraction elicited after 10 s of rest after 2-Hz stimulation much less than the steady-state contraction at 0.1 Hz (beat interval 10 s). Thiopental inhibited the postrest contraction (no ryanodine present) more strongly than did Ni2+ (an inhibitor of the transsarcolemmal Ca2+ influx) when the contraction at 0.1 Hz in the presence of ryanodine was inhibited to the same extent.

CONCLUSIONS

These results suggest that thiopental decreases sarcoplasmic reticulum Ca2+ release induced by electrical stimulation and inhibits the ryanodine-induced efflux of sarcoplasmic reticulum Ca2+.

Effect of cardiopulmonary bypass on the circulating level of soluble GMP-140

Soluble GMP-140 can prevent the adhesion of activated neutrophils to endothelium in vitro. Because cardiopulmonary bypass causes neutrophil-endothelial interaction, the plasma level of soluble GMP-140 was measured using an enzyme immunoassay system in 32 children undergoing intracardiac repair of congenital heart disease. They had either a high, low, or normal pulmonary blood flow (n = 13, 12, and 7 respectively). Because activated platelets are a source of GMP-140, the plasma beta-thromboglobulin level was also measured. Blood was sampled before, during, and for 24 hours after cardiopulmonary bypass. Plasma levels of both soluble GMP-140 and beta-thromboglobulin increased after the onset of cardiopulmonary bypass in all patients but for both substances the increase was greater in those with a low pulmonary blood flow (p < 0.05 for all comparisons). The sum total of soluble GMP-140 values during and after operation was correlated negatively with the preoperative mean pulmonary arterial pressure (p < 0.05 for all time intervals). GMP-140 level correlated with the plasma beta-thromboglobulin level (r = 0.5, p < 0.05). This work supports the contention that soluble GMP-140 is released from activated platelets during cardiopulmonary bypass, the level being particularly high in those who had intrinsically abnormal platelets preoperatively in association with a low pulmonary blood flow. Patients with a high pulmonary blood flow, who are more susceptible to endothelial cell injury, may be less well protected by soluble GMP-140.

[Sarcoplasmic reticular calcium release and myocardial protection--effect of ryanodine on myocardial ischemia and reperfusion-induced injury]

Calcium release from sarcoplasmic reticulum (SR) may contribute to the intracellular calcium overload observed during myocardial ischemia and reperfusion. We have therefore investigated the ability of ryanodine to enhance myocardial protection when given before ischemia or during reperfusion in the isolated working rat heart. Hearts (n = 6-9/group) from male Wistar rats were aerobically (37 degrees C) perfused (20 min) with bicarbonate buffer (Ca2+ = 2.4 mM). In the first series of studies, this was followed by a 3 min infusion of St Thomas' Hospital cardioplegic solution containing various concentrations of ryanodine. Hearts were then subjected to 38 min of normothermic (37 degrees C) global ischemia and 35 min of reperfusion (15 min Langendorff, 20 min working). The recoveries of aortic flow (%AF) were 50.3 +/- 2.5% in the ryanodine free controls versus 55.2 +/- 5.8, 72.0 +/- 1.3 (p < 0.05), 61.0 +/- 4.3, 51.8 +/- 5.1 and 32.1 +/- 5.0 (p < 0.05)% in the 0.88, 1.75, 2.13, 2.50 and 10.00 nM ryanodine groups, respectively. Creatine kinase (CK) leakage during Langendorff reperfusion was reduced in the 1.75 nM group but was similar to control in all other groups. In the second series of studies, 3 min of cardioplegia without ryanodine and 38 min of ischemia (37 degrees C) were followed by 15 min of Langendorff reperfusion with 0, 0.09, 0.18, 0.88 or 1.75 nM ryanodine, %AF was 59.3 +/- 3.3%, 54.7 +/- 3.3, 53.8 +/- 3.5, 38.4 +/- 8.9 (p < 0.05) and 33.3 +/- 5.8 (p < 0.05)% in the 0, 0.09, 0.18, 0.88 and 1.75 nM ryanodine groups, respectively. CK leakage tended to increase dose-dependently.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of lung injury during open heart operations for congenital heart defects

To elucidate free radical-induced lung injury associated with open heart operations for congenital heart defects, we studied 23 such patients. Maximum plasma chemiluminescence level (a marker of peroxylipids) in patients with pulmonary hypertension (n = 8) was higher than in patients with cyanotic disease (n = 8) (1,115.4 +/- 189.9 versus 728.8 +/- 48.3 counts; p < 0.05). There was a significant correlation between the maximum chemiluminescence level and preoperative pulmonary to systemic arterial pressure ratio (r = 0.929; p < 0.05). To investigate the effect of allogeneic leukocytes, we compared pulmonary hypertensive patients without allogeneic leukocyte transfusion during operation (n = 7) with the group with pulmonary hypertension. Both maximum chemiluminescence level during bypass (712.4 +/- 24.9 versus 1,115.4 +/- 189.9 counts; p < 0.05) and percent decrease in pulmonary arterial pressure after bypass (44.7% +/- 6.2% versus 28.2% +/- 4.5%; p < 0.05) were significantly improved, suggesting that depletion of leukocytes decreased the lung injury induced by free radical reaction.

Increased plasma levels of endothelin-1 after cardiopulmonary bypass in patients with pulmonary hypertension and congenital heart disease

The plasma level of the potent vasoconstrictor endothelin-1 was measured in children who underwent cardiac operations. Forty-five patients were divided into two groups, those with a high pulmonary blood flow (HF group; n = 23) and those with a normal or low flow (NF group; n = 22). Seven blood samples were taken: immediately before cardiopulmonary bypass, immediately after removing the aortic cross-clamps, immediately after discontinuing bypass, and at 20 minutes and 3, 6, and 24 hours after termination of bypass. The plasma levels of endothelin-1 were similar in both groups before bypass. From the time the aortic crossclamps were removed, the plasma endothelin-1 levels in both groups increased significantly, to reach a peak level at 3 to 6 hours. The increase was significantly greater in the HF than in the NF group, and the maximum values in the two groups were 12.6 +/- 1.1 and 9.6 +/- 0.8 fmol/ml, respectively (mean +/- standard error of the mean, p < 0.05). The value 20 minutes after bypass showed a positive correlation with the mean pulmonary arterial pressure measured at the preoperative cardiac catheterization study (r = 0.41, p < 0.05). In addition, a significant positive correlation was obtained between endothelin-1 3 hours after bypass and the maximum pulmonary/systemic arterial pressure ratio during the first 12 hours after operation (r = 0.86, p < 0.05). These results suggest that cardiopulmonary bypass is associated with an immediate postoperative increase in circulating endothelin and that patients who had a high pulmonary blood flow before the operation are particularly vulnerable, bypass having a more injurious effect on a lung with preexisting endothelial dysfunction. A high level of circulating endothelin may predispose to pulmonary vascular lability and pulmonary hypertensive crises in the postoperative period.

Effects of inhibition of transsarcolemmal calcium influx by nickel on force of postrest contraction and on contracture induced by rapid cooling

OBJECTIVE

The aim was to characterise the influence of a decrease in transsarcolemmal calcium influx on the calcium content of the sarcoplasmic reticulum and on the force of postrest contraction, which is largely activated by calcium released from the sarcoplasmic reticulum.

METHODS

Isometric force of postrest contractions in isolated rabbit papillary muscles was measured in the absence and in the presence of ryanodine (1 microM). The force measured in the presence of ryanodine was used as an index of transsarcolemmal calcium influx. The calcium content of the sarcoplasmic reticulum was estimated by rapid cooling induced contracture measurements. Nickel (Ni2+) was used to decrease the calcium influx, and the results were compared to those obtained by lowering the extracellular calcium concentration.

RESULTS

The addition of Ni2+ or lowering extracellular Ca2+ markedly decreased the force of postrest contraction measured in the presence of ryanodine, and moderately decreased the force of postrest contraction measured in the absence of ryanodine. Neither the addition of Ni2+ nor lowering extracellular Ca2+ decreased maximum rapid cooling induced contracture; this was actually increased in the presence of Ni2+ even though a larger number of stimuli was required in the presence than in the absence of Ni2+ for the force of the subsequently elicited contracture to reach the maximum level.

CONCLUSIONS

The results suggest: (1) that a decrease in the calcium influx reduces the force of the postrest contraction by decreasing the amount of calcium required to trigger the release of calcium from the sarcoplasmic reticulum, without decreasing its maximum calcium content; and (2) that Ni2+ decreases the rate of filling of sarcoplasmic reticular calcium stores even though the calcium content of the sarcoplasmic reticulum after a sufficiently large number of beats is higher in the presence of Ni2+ than in its absence.

Increased lung injury in pulmonary hypertensive patients during open heart operations

To investigate lung injury in adult open heart operations during extracorporeal circulation, we measured plasma chemiluminescence levels. Nineteen patients were divided into two groups depending on preoperative pulmonary artery pressure: a pulmonary hypertension group (n = 11) and a control group (n = 8). Plasma samples were taken simultaneously from arterial and central venous lines at six different points during and early after operation. Arteriovenous difference of chemiluminescence (counts/10 seconds) increased significantly only in the pulmonary hypertension group (from -19.1 +/- 8.3 at the end of cross-clamping to 23.7 +/- 12.4 at the end of bypass; p < 0.01). There was a positive correlation between peak values of arterial plasma chemiluminescence and postoperative respiratory index in the pulmonary hypertension group (p < 0.05). In addition, during the first 12 hours postoperatively, arteriovenous difference of chemiluminescence in the pulmonary hypertension group changed significantly from negative to positive values (p < 0.05). These data suggest that free radical activity (detected by chemiluminescence) was deeply involved in lung injury during and also early after open heart operations, especially in pulmonary hypertensive patients.