Transcatheter atrial septal defect closure late after completion of biventricular circulation in patients with pulmonary atresia intact ventricular septum or critical pulmonary stenosis

OBJECTIVE

This study aimed to explore anatomical and hemodynamic features of atrial septal defect, which was treated by transcatheter device closure late after completion of biventricular circulation in patients with pulmonary atresia and intact ventricular septum (PAIVS) or critical pulmonary stenosis (CPS).

METHODS

We studied echocardiographic and cardiac catheterization data, including defect size, retroaortic rim length, single or multiple defects, the presence of malalignment atrial septum, tricuspid and pulmonary valve diameters, and cardiac chamber sizes, in patients with PAIVS/CPS who underwent transcatheter closure of atrial septal defect (TCASD), and compared to control subjects.

RESULTS

A total of 173 patients with atrial septal defect, including 8 patients with PAIVS/CPS, underwent TCASD. Age and weight at TCASD were 17.3 ± 18.3 years and 36.6 ± 13.9 kg, respectively. There was no significant difference in defect size (13.7 ± 4.0 vs. 15.6 ± 5.2 mm, p = 0.317) and the retro-aortic rim length (3.7 ± 4.3 vs. 3.6 ± 0.3.1 mm, p = 0.948) between the groups; however, multiple defects (50% vs. 5%, p < 0.001) and malalignment atrial septum (62% vs. 14%. p < 0.001) were significantly frequent in patients with PAIVS/CPS compared to control subjects. The ratio of pulmonary to systemic blood flow in patients with PAIVS/CPS was significantly lower than that in the control patients (1.2 ± 0.4 vs. 2.0 ± 0.7, p < 0.001); however, four out of eight patients with atrial septal defect associated with PAIVS/CPS had right-to-left shunt through a defect, who were evaluated by the balloon occlusion test before TCASD. The indexed right atrial and ventricular areas, the right ventricular systolic pressure, and mean pulmonary arterial pressure did not differ between the groups. After TCASD, the right ventricular end-diastolic area remained unchanged in patients with PAIVS/CPS, whereas it significantly decreased in control subjects.

CONCLUSIONS

Atrial septal defect associated with PAIVS/CPS had more complex anatomy, which would be a risk for device closure. Hemodynamics should be individually evaluated to determine the indication for TCASD because PAIVS/CPS encompassed anatomical heterogeneity of the entire right heart.

Coronary anomalies associated with ventricular septal defect

Coronary anomalies encompass different conditions in terms of anomalous origin, coursing, and branching, which are occasionally associated with congenital heart disease. This study aimed to explore coronary anomalies associated with ventricular septal defect that was a stereotypical congenital heart disease. We retrospectively reviewed angiographic findings in patients with ventricular septal defect who required corrective surgery, and identified coronary abnormalities, including anomalous origin, coursing, and branching of coronary arteries based on angiography. We studied the prevalence and types of coronary anomalies among them. A total of 998 patients with ventricular septal defect was studied. Age and weight were 2.0 (2.1-15.2) months and 5.7 (4.1-8.7) kg, respectively. There were 115 patients (12%) with syndrome or genetic disorder, and 34 patients (3%) with extracardiac major organ anomalies. The overall prevalence of coronary anomalies was 6.2%. All coronary anomalies were anomalous origin and coursing, among 3 patients accompanied anomalous intrinsic coronary anatomy. Originating within aortic root above the Valsalva sinus was the most common coronary anomaly. Coronary anomalies were independently correlated with bicuspid aortic valve (odds ratio [OR]: 8.02, 95% confidence interval [CI]: 2.34-23.4) and persistent left superior caval vein (OR: 5.02, 95% CI: 1.93-11.7). We showed the possibility that minor cardiac variants, such as bicuspid aortic valve and persistent left superior caval vein, contribute to higher prevalence of coronary anomalies in patients with ventricular septal defect.

Feasibility and Safety of Sodium Glucose Cotransporter-2 Inhibitors in Adults with Heart Failure after the Fontan Procedure

Sodium glucose cotransporter-2 (SGLT-2) inhibitors have been widespread in patients with heart failure; however, there is little information regarding its feasibility and safety among patients after the Fontan procedure. We presented five adults after the Fontan procedure who were treated with SGLT-2 inhibitors. All patients reduced oedema and/or pleural effusion despite other conjunct medications were ineffective. Although we did not measure the urine volume in all patients, all patients themselves reported an increase in urinary output after the administration of a SGLT-2 inhibitor. In addition, administration of a SGLT-2 inhibitor resulted in weight loss (4/5), an increase in systemic oxygen saturation (4/5), an increase in serum albumin level (4/5), an increase in estimated glomerular filtration ratio (4/5), and a decrease in plasma brain natriuretic peptide level (4/5). Our case series supported the feasibility and safety of SGLT-2 inhibitors in patients with Fontan circulatory failure, although the exact changes in urinary output were unknown in all patients. Further investigation will be required to explore a diuretic effect by SGLT-2 in patients after the Fontan procedure.

Overgrowth of the Amygdala in Children with Single Ventricle Congenital Heart Disease

Aim: Early life stress is associated with overgrowth of the amygdala, which plays a key role in the processing and memory of emotional responses. Herein, we aimed to explore the amygdala volume in children with single-ventricle congenital heart disease who experience repeated admissions during the neonatal period and infancy. Methods: We compared the amygdala volume measured using brain magnetic resonance imaging (MRI) between 40 patients after completion of the Fontan procedure and 40 age- and sex-matched control subjects Results: Age at the MRI study were 9.2 (8.5-11.1) and 10.2 (9.2-10.3) years in the Fontan and control groups, respectively. The maximum amygdala volume in the Fontan group was significantly larger than in the control group (1232 [983-1392] mm³/m² vs. 980 [728-1166] mm³/m², P < 0.001). The amygdala volume did not correlate to cardiac index (r  =  0.260) and central venous pressure (r = -0.107) in the Fontan group. Conclusions: Children with single-ventricle congenital heart disease exhibited amygdala overgrowth.

Ventricular Repolarization Dispersion is a Potential Risk for the Development of Life-Threatening Arrhythmia in Children with Hypertrophic Cardiomyopathy

The risk stratification and early interventions are necessary in patients with hypertrophic cardiomyopathy (HCM), as life-threatening arrhythmia (LTA) is a leading cause of death. This study aimed to explore whether an interval between the peak of the T wave to the end terminal of the T wave (Tp-e), which represents ventricular repolarization dispersion, could predict the risk for LTA in children with HCM. We analyzed electrocardiography at the first and last visits in children (aged < 15 years) with HCM, and compared Tp-e interval and the ratio of Tp-e interval to QT interval (Tp-e/QT) between children with and without LTA. We studied 25 children with HCM. During the follow-up of 85 (38-146) months, there were 7 children with LTA. The 5-year sudden cardiac death (SCD) risk was 1.4 (1.1-2.5) %, which suggested that our cohort consisted of patients at a lower risk for SCD. Age was significantly older in children with LTA compared to those without it (12.5 vs.1.0 years, P = 0.037), although sex, the presence of family history and symptoms at diagnosis, the maximum left ventricular wall thickness Z-score did not differ between the groups. At the last electrocardiography before LTA, corrected Tp-e interval and Tp-e/QT ratio were significantly greater in patients with LTA compared to those in patients without LTA (corrected Tp-e: 103 vs. 78 ms, P = 0.020; Tp-e/QT: 0.28 vs. 0.22, P = 0.046). Corrected Tp-e and Tp-e/QT ratio cutoff values of 91 ms and 0.28 yielded as the predictors for LTA with sensitivity of 85% and 72%, specificity of 71% and 89%, respectively. Prolonged absolute and corrected Tp-e intervals and an increase in the Tp-e/QT ratio can be useful predictors for LTA in children with HCM. We offer temporal assessments of ventricular repolarization dispersion to stratify the risk for the development of LTA/SCD among children with HCM.

Being Overweight Is Related to Neoaortic Sinus Dilatation After Arterial Switch Operation

Background

Neoaortic sinus dilatation is a late comorbidity after an arterial switch operation in patients with dextro-transposition of the great arteries. We aim to explore whether neoaortic sinus dilatation is related to overweight or obesity, as these affect aortic remodeling in such patients.

Methods

We measured neoaortic diameters including those for the annulus, sinus, sinotubular junction, and ascending aorta by echocardiography and studied the relationship between these diameters and body mass index in patients aged 15 years and older after an arterial switch operation.

Results

A total of 45 patients were studied. Median (interquartile range) age, body mass index, and systolic blood pressure at echocardiography were 20 (17–28) years, 21.2 (18.4–24.2) kg/m2, and 120 (112–127) mm Hg, respectively. Echocardiogram revealed the following median values (interquartile ranges): neoaortic annulus diameter, 22.2 (19.8–23.8) mm; sinus diameter, 34.6 (31.8–39.8) mm; sinotubular junction diameter, 27.5 (22.4–30.0) mm; and ascending aortic diameter, 20.4 (19.4–22.7) mm. The neoaortic sinus diameter was significantly correlated with body mass index (r = 0.41, P = .004) and was significantly larger in patients with concomitant ventricular septal defect (P &lt; .001) and those who were over-weight (body mass index ≥25 kg/m2; P = .006).

Conclusion

Neoaortic sinus dilatation after an arterial switch operation is associated with being overweight during adolescence and young adulthood. It is important to prevent obesity in patients after an arterial switch operation and educate them on a healthy lifestyle.

Home High-Flow Nasal Cannula Therapy in Children with Congenital Heart Disease

High-flow nasal cannula (HFNC) therapy has been applied in the perioperative respiratory care for children with congenital heart disease and respiratory problems. However, the information about the feasibility of home HFNC therapy remains lacking among them. We retrospectively reviewed 5 children with congenital heart disease and respiratory problems who underwent home HFNC therapy, and evaluated their feasibility and safety. Age and weight at the introduction of home HFNC therapy were 19 (2-119) months and 5.3 (3.1-11.4) kg, respectively. All subjects had chromosomal anomaly including trisomy 18 in 3 and trisomy 21 in 2 subjects. Cardiac diagnoses included ventricular septal defect in 3, tetralogy of Fallot with complete atrioventricular septal defect in one, and pulmonary atresia with ventricular septal defect in another subject. Other comorbidities involved pulmonary hypertension in 4, micrognathia in 4, West syndrome in one, and bronchial asthma in one subject. Respiratory manifestations involved cyanosis due to upper airway obstruction in 2 and central hypopnea in 2, and recurrent pneumonia in one subject. After home HFNC therapy, systemic oxygen saturation significantly increased from 60 (40-78)% to 83 (83-96)% (P = 0.04), while heart rate and blood partial pressure of carbon dioxide were significantly decreased. There was no adverse event relevant to home HFNC during the follow-up period of 12 (5-49) months. Among them, one patient subsequently underwent tracheotomy at 11 years of age, and two patients weaned to conventional home oxygen therapy at 7 and 23 months of age. Home HFNC is safe and feasible in children with congenital heart disease and respiratory problems.

Coronary arterial dominance in patients with congenital heart disease

Coronary arterial dominance is concerned in the management of ischemic heart disease. In particular, right coronary arterial dominance is having a risk for three-vessel coronary artery disease. Thus, this study aimed to explore coronary arterial dominance in patients with congenital heart disease. The study involved 250 patients, of which 105 patients were with tetralogy of Fallot (TOF), 100 patients with ventricular septal defect (VSD), and 45 patients with Kawasaki disease (KD). We retrospectively reviewed their ascending aortography to determine their coronary arterial dominance, Z-scores of coronary artery diameter, and the ascending aortic curvature, which pertained to the angle between the aortic annulus plane and ascending aortic plane. We identified relevant factors that contribute to having right coronary arterial dominance. Age and weight of the 250 subjects were 2.9 (1.0-8.7) months and 7.7 (5.0-9.4) kg, respectively. The Z-scores of right coronary and anterior descending arteries significantly differed among patients with TOF, VSD, and KD (P < 0.001, P = 0.001). However, there were no significant differences in the Z-scores of left main trunk and circumflex arteries. Right coronary arterial dominance occurred in 89%, 49%, and 61% in patients with TOF, VSD, and KD, respectively (P < 0.001). The presence of TOF was the most powerful predictor for right coronary arterial dominance (odds ratio: 10.31, 95% confidence interval: 4.11-27.2, P < 0.001). We found the robust relationship between right coronary arterial dominance and TOF. Patients with TOF may have an increased risk for the development of coronary artery disease during adulthood.

Long-Term Outcomes After an Individualized Strategy in Patients with Pulmonary Atresia and Intact Ventricular Septum

This retrospective cohort study aimed to explore the long-term outcomes of an individualized strategy in patients with pulmonary atresia and intact ventricular septum (PAIVS). We analyzed survival and reintervention rates and identified risk factors for outcomes in patients with PAIVS treated based on individual right heart structures between 1979 and 2019. Ninety-five patients were included in this study. The z-scores of the pulmonary annulus, tricuspid annulus, and right ventricular end-diastolic volume were - 3.30 (- 15.15 to 1.83), - 0.70 (- 4.65 to 2.33), and - 1.51 (- 6.35 to 1.18), respectively. Right ventricular-dependent coronary circulation occurred in 15% of the patients. Among the 63 patients attempting biventricular strategy at first, 55 patients achieved biventricular circulation, 3 patients had one-and-a-half circulation, and 4 patients died perioperatively. Among the 33 patients attempting univentricular strategy at first, 10 patients died before the completion of Fontan operation, 17 patients (48%) accomplished Fontan operation, and 5 patients waited for Fontan operation. In one patient, conversion to biventricular circulation occurred. During the follow-up period of 720 person-years, the 20-year survival rate was significantly higher in patients with biventricular circulation than in those patients with univentricular circulation (93% vs. 67%, P < 0.001). Freedom from reintervention rates at 20 years was significantly lower in patients with biventricular circulation than in those patients with univentricular circulation (29% vs. 72%, P < 0.001). The pulmonary annulus z-score was an independent risk factor for reintervention in patients with biventricular circulation. Patients with biventricular circulation had an acceptable survival rate, but a high reintervention rate. Meanwhile, patients with univentricular circulation had high mortality before the completion of Fontan operation, although the reintervention rate was relatively low.

Comprehensive assessments of pulmonary circulation in children with pulmonary hypertension associated with congenital heart disease

Pulmonary hypertension associated with congenital heart disease (CHD-PH) encompasses different conditions confounded by the left-to-right shunt, left heart obstruction, ventricular dysfunction, hypoxia due to airway obstruction, dysplasia/hypoplasia of the pulmonary vasculature, pulmonary vascular obstructive disease, and genetic variations of vasoactive mediators. Pulmonary input impedance consists of the pulmonary vascular resistance (Rp) and capacitance (Cp). Rp is calculated as the transpulmonary pressure divided by the pulmonary cardiac output, whereas Cp is calculated as the pulmonary stroke volume divided by the pulmonary arterial pulse pressure. The plots of Rp and Cp demonstrate a unique hyperbolic relationship, namely, the resistor-capacitor coupling curve, which represents the pulmonary vascular condition. The product of Rp and Cp is the exponential pressure decay, which refers to the time constant. Alterations in Cp are more considerable in CHD patients at an early stage of developing pulmonary hypertension or with excessive pulmonary blood flow due to a left-to-right shunt. The importance of Cp has gained attention because recent reports have shown that low Cp potentially reflects poor prognosis in patients with CHD-PH and idiopathic pulmonary hypertension. It is also known that Cp levels decrease in specific populations, such as preterm infants and trisomy 21. Therefore, both Rp and Cp should be individually evaluated in the management of children with CHD-PH who have different disease conditions.

Pulmonary vascular resistance and compliance in individuals with trisomy 18

Individuals with trisomy 18 (T18) usually have congenital heart disease, often with pulmonary hypertension, which is associated with poor outcomes. This study aimed to explore the characteristics of pulmonary circulation including pulmonary vascular resistance (Rp) and compliance (Cp) among them. We retrospectively reviewed cardiac catheterization data in subjects with T18, trisomy 21 (T21), and without chromosomal anomaly (control group) who were referred due to heart failure associated with ventricular septal defect between 2000 and 2020. Pulmonary hemodynamic parameters including Rp and Cp were compared between these groups. We studied 20 subjects with T18, 88 subjects with T21, and 240 control subjects. There was no significant difference in age (T18: 4.6 [3.0-6. 9] vs. T21: 2.8 [1.9-4.0] vs. control: 2.9 [1.6-3.2] months, p = 0.06) and mean pulmonary arterial pressure (T18: 41 [33-49] vs. T21: 35 [30-41] vs. control: 36 [28-43] mmHg, p = 0.121) between the groups. The pulmonary to systemic blood flow ratio (Qp/Qs) (p = 0.983), Rp (p = 0.449), and Cp (p = 0.195) did not differ between T18 and control groups. However, Qp/Qs and Cp in T18 group were significantly greater than that in T21 group (T18: Qp/Qs: 3.4 [2.3-5.2] vs. T: 21 2.3 [1.7-3.7], p = 0.001. Cp: 3.5 [2.3-5.5] vs. 2.3 [1.6-3.1] mmHg/mL/m² , p = 0.007), while Rp was identical between the groups (T18: 2.0 [1.6-3.3] vs. T21: 2.3 [1.7-3.7], p = 0.386). The pulmonary circulation in T18 subjects differed from that observed in T21 subjects, and identical to that observed in control subjects. Pulmonary hypertension is expected to be normalized after reasonable corrective surgery in T18 patients with congenital heart disease.

Late adverse events in patients with pulmonary atresia intact ventricular septum after valvuloplasty

BACKGROUND

We aimed to explore the relationship between temporal right heart growth and long-term outcomes in patients with pulmonary atresia with intact ventricular septum (PA/IVS) who underwent balloon pulmonary valvulopalsty (BPV).

METHODS

Echocardiography was performed to measure the pulmonary valve diameter (PVD), the right atrial end-systolic area (RAA), and the right ventricular end-diastolic area (RVA) before BPV, 1 and 5 years after BPV. The primary and secondary endpoints were to explore temporal changes in the right heart structures and to determine echocardiographic parameters related to late adverse events (LAEs).

RESULTS

In 31 patients, PVD significantly increased after BPV, whereas TVD remained unchanged throughout the follow-up period of 9.1 (5.7-12.0) years. After BPV, RAA temporally decreased, whereas RVA significantly increased. There were six LAEs (19%); arrhythmias in two, heart failure in one, reintervention of the right ventricular outflow tract in one, and reintervention for residual cyanosis in two. The rate of freedom from LAEs at 5 and 10 years were 92% and 82%, respectively. RAA temporally decreased in patients without LAEs (P<0.01); however, RAA remained unchanged throughout the period in patients with LAEs (P=0.16). Moderate or severe pulmonary regurgitation (PR) (hazard ratio [HR], 23.0; 95% confidence interval [CI], 1.3-385; P=0.03) and the ratio of RVA /RAA at 1 year after BPV (HR, 6.3×10^-11; 95%CI, 2.1×10^-20-0.19; P=0.03) were independent risk factors for LAEs.

CONCLUSIONS

Disproportional right heart growth was observed in patients with PA/IVS after BPV. PR and increased RAA are crucial in identifying the burden of LAEs among them.

Catastrophic intracranial hemorrhage associated with eosinophilic granulomatous polyangiitis in a patient after Fontan operation

A 29-year-old man after the Fontan operation had a catastrophic intracranial hemorrhage associated with eosinophilic granulomatous polyangiitis. Despite combination therapy with cyclophosphamide and methylprednisolone, he was dead at 6 months after the onset. The clinical course was worse owing to underlying coagulopathy and endothelial dysfunction associated with congenital heart disease. Key Clnical Massage The majority of patients with complex congenital heart disease survive into adulthood. Potential endothelial dysfunction and coagulopathy can attribute to unexpected clinical manifestations of other extracardiac disease among them.

Headache and Left Ventricular Efficiency After Transcatheter Closure of Atrial Septal Defect

OBJECTIVE/BACKGROUND

This study aimed to clarify the relationship between migraine-like headache and ventriculo-arterial coupling after transcatheter closure of the atrial septal defect in children. We hypothesized that migraine headache after defect closure would be related to an abnormal hemodynamic response against an increased left ventricular filling.

DESIGN

A retrospective cohort study.

METHODS

We calculated the end-ventricular systolic elastance (Ees), effective arterial elastance (Ea), and ventricular energy efficiency approximated based on echocardiography before and after defect closure, and compared these parameters between the subjects with and without headache after defect closure.

RESULTS

A total of 167 subjects were studied. Age at the procedure, defect diameter, and pulmonary to systemic blood flow ratio were 11 (9-17) years, 12.8 (9.2-16.0) mm, and 1.8 (1.6-2.3), respectively. We identified 47 (28%) subjects with migraine headache after defect closure. Although there was no significant difference in the Ees, Ea, and ventricular energy efficiency before defect closure between the groups, the Ees (4.0 [3.4-4.9] vs 4.8 [3.7-6.1], P = .014) and ventricular energy efficiency (0.79 [0.76-0.82] vs 0.83 [0.79-0.85], P = .001) after defect closure in subjects with headache were significantly lower than those in subjects without headache. Migraine headache after defect closure was significantly associated with age (odds ratio: 0.97, 95% confidential interval: 0.94-1.00, P = .036) and a decrease in the ventricular energy efficiency after defect closure (odds ratio: 6.42, 95% confidential interval: 2.76-14.90, P < .001).

CONCLUSION

A loss of ventricular energy efficiency was common in pediatric subjects with migraine-like headache after transcatheter closure of the atrial septal defect, which suggested that the left ventricular function maladaptation was related to headache development after defect closure. We advocate that an impaired ventriculo-arterial coupling may be one of the mechanisms for developing attacks in not only this population but also in other patients with migraine.

Cytomegalovirus-associated hemophagocytic syndrome in a patient with adult onset Still's disease

Reactive hemophagocytic syndrome (HPS) is characterized by hemophagocytosis by activated histiocytes, resulting in pancytopenia and liver dysfunction. We describe a patient with adult onset Still's disease (AOSD) in whom HPS developed. An 80-year-old Japanese woman with high fever, arthralgia, skin rash, and pleuritis was admitted to our hospital for further examination. She was diagnosed with AOSD and steroid therapy was initiated. During the course of steroid therapy, a re-elevation of serum ferritin levels and a marked increase in serum transaminase were observed. Bone marrow aspiration revealed an increase in the number of histiocytes with hemophagocytosis and cytomegalovirus (CMV)-positive leukocytes were detected. At this time we diagnosed the patient as having virus-associated hemophagocytic syndrome (VAHS) and elevated levels of trasaminase and ferritin were normalized by ganciclovir treatment. Reactive HPS occurs in cases of active AOSD. However, it should be noted that HPS may be accompanied by opportunistic infections during immunosuppressive therapy requiring prompt antibiotic therapy.

Thyroid lymphoma of mucosa-associated lymphoid tissue with monoclonal gammopathy occurring in an atomic bomb survivor: report of a case

We describe herein a case of thyroid lymphoma of the mucosa-associated lymphoid tissue (MALT) with monoclonal gammopathy (IgG kappa), occurring in a woman who was exposed to atomic-bomb (A-bomb) radiation 1.5 km from the explosion of the hypocenter when she was 31 years old. Her estimated radiation dose was 0.2 Gy. A total thyroidectomy resulted in the disappearance of monoclonal gammopathy, thus indicating extramedullary monoclonal gammopathy of the thyroid. Three patterns of protein electrophoresis, i.e., normal, the appearance of monoclonal immunoglobulins, and their disappearance after the total thyroidectomy, were consecutively recorded. The utility of checking of the monoclonal immunoglobulin levels after a thyroidectomy due to lymphoma of the MALT to monitor recurrence is therefore suggested. This lymphoma is most likely not related to the patient's A-bomb radiation exposure.

Long-term effects of dietary alpha-linolenic acid from perilla oil on serum fatty acids composition and on the risk factors of coronary heart disease in Japanese elderly subjects

Although important roles of dietary n-3 fatty acids in the prevention of coronary heart disease (CHD) have been suggested, long-term effects of dietary alpha-linolenic acid (ALA, 18:3n-3) have not yet been established under controlled conditions. We tested whether a moderate increase of dietary ALA affects fatty acids composition in serum and the risk factors of CHD. Oxidized LDL (OxLDL) was directly measured by ELISA using antibody specific to OxLDL. By merely replacing soybean cooking oil (SO) with perilla oil (PO) (i.e., increasing 3 g/d of ALA), the n-6/n-3 ratio in the diet was changed from 4:1 to 1:1. Twenty Japanese elderly subjects were initially given a SO diet for at least 6 mo (baseline period), a PO diet for 10 mo (intervention period), and then returned to the previous SO diet (washout period). ALA in the total serum lipid increased from 0.8 to 1.6% after 3 mo on the PO diet, but EPA and DHA increased in a later time, at 10 mo after the PO diet, from 2.5 to 3.6% and 5.3 to 6.4%, respectively (p<0.05), and then returned to baseline in the washout period. In spite of increases of serum n-3 fatty acids, the OxLDL concentration did not change significantly when given the PO diet. Body weight, total serum cholesterol, triacylglycerol, glucose, insulin and HbA1c concentrations, platelet count and aggregation function, prothrombin time, partial thromboplastin time, fibrinogen and PAI-1 concentration, and other routine blood analysis did not change significantly when given the PO diet. These data indicate that, even in elderly subjects, a 3 g/d increase of dietary ALA could increase serum EPA and DHA in 10 mo without any major adverse effects.

Prevalence rate of thyroid diseases among autopsy cases of the atomic bomb survivors in Hiroshima, 1951-1985

To examine the radiogenic risk of latent thyroid cancer, thyroid adenoma, colloid/adenomatous goiter and chronic thyroiditis, the data for 3821 subjects collected in the course of autopsies of atomic bomb survivors in Hiroshima from 1951 to 1985 by the Radiation Effects Research Foundation (RERF) were analyzed using a logistic model. About 80% of the autopsies were performed at RERF and the remainder at local hospitals. The frequencies of the above diseases were not associated with whether the underlying cause of death was cancer. However, note that our results may be influenced by potentially biasing factors associated with autopsy selection. The relative frequency of latent thyroid cancer (greatest dimension < or = 1.5 cm but detectable on a routine microscopic slide of the thyroid gland) increased as the radiation dose increased and was about 1.4-fold greater at 1 Gy than in the 0-Gy dose group. The relative occurrence of thyroid adenoma also increased as radiation dose increased, and was about 1.5-fold greater at 1 Gy than in the 0-Gy dose group. Sex, age at the time of the bombing or period of observation did not significantly modify the radiogenic risks for thyroid adenoma or latent thyroid cancer. No statistically significant association was found between radiation exposure and the rates of colloid/adenomatous goiter and chronic thyroiditis. The possible late effect of atomic bomb radiation on the frequency of benign thyroid diseases is discussed on the basis of these data.

[Mitral valve replacement with concomitant coronary bypass for the papillary muscle rupture after acute myocardial infarction in situs inversus]

A 53-year-old man, who was known to have situs inversus totalis all of his life, had acute myocardial infarction complicated by partial rupture of the posterior papillary muscle causing mitral regurgitation and pulmonary edema. The patient underwent mitral valve replacement (Omnicarbon 27 mm) with concomitant aortocoronary saphenous vein bypass, and he is now doing well 9 months following the operation. To our knowledge, this is the first case of the successful mitral valve replacement and concomitant aortocoronary saphenous vein bypass on a patient with situs inversus totalis (mirror-image dextrocardia) in Japan.

Analysis of thyroid carcinoma based on material registered in Japan during 1977-1986 with special reference to predominance of papillary type

BACKGROUND

As geographic differences have been observed in the characteristics of thyroid carcinoma, an analysis was made on thyroid carcinoma in the iodine rich country of Japan.

METHODS

A total of 10,973 patients with histologically confirmed thyroid carcinoma registered in Japan from 1977-1986 were analyzed. Cases detected incidentally at autopsy and cases of nonepithelial tumor were excluded. This series included approximately 27% of all thyroid carcinoma cases in Japan.

RESULTS AND CONCLUSIONS

Histologic distribution showed that papillary carcinoma accounted for 78.4% of cases, follicular carcinoma accounted for 17.2%, medullary carcinoma for 1.4%, squamous cell carcinoma for 0.3%, and anaplastic carcinoma for 2.7%. There is a tendency in Japan to diagnose papillary carcinoma as follicular carcinoma and to diagnose malignant lymphoma as anaplastic carcinoma. It was considered that the percentage of papillary carcinoma was higher and the percentage of follicular carcinoma and anaplastic carcinoma was lower than foregoing values. The characteristics of thyroid carcinoma in Japan were described, and the low incidence of nonpapillary carcinoma compared with papillary carcinoma was discussed in relation to iodine excess as an etiologic factor.

Hyperparathyroidism among atomic bomb survivors in Hiroshima

To determine the effect of exposure to atomic bomb radiation on the occurrence of hyperparathyroidism, the prevalence was determined among a population of 3,948 atomic bomb survivors and their controls in Hiroshima. The diagnosis of hyperparathyroidism was based upon histopathological findings or the presence of consistent hypercalcemia and elevated levels of serum parathyroid hormone. Primary hyperparathyroidism was diagnosed in 19 persons (3 males, 16 females). Females had approximately a threefold higher overall prevalence of hyperparathyroidism than males (P less than 0.05). The prevalence rates of hyperparathyroidism increased with radiation dose (chi2(1) = 12, P less than 0.001) after adjusting for sex and age at the time of the bombing. The estimated relative risk was 4.1 at 1 Gy (95% confidence limits 1.7 to 14). There was some evidence that the effect of radiation was greater for individuals who were younger at the time of the bombing. In conclusion, exposure to atomic bomb radiation affected the occurrence of hyperparathyroidism, suggesting that doses of radiation lower than those used in radiotherapy may also induce this disorder.

[Four cases of spontaneous pneumothorax with no reexpansion of collapsed lung despite chest tube drainage]

We report four cases of spontaneous pneumothorax with no reexpansion of the collapsed lung despite chest tube placement and adequate suction. The cause of absence of reexpansion was endobronchial obstruction by bronchogenic carcinoma in one patient and by sputum plug in another. In the other two patients, the collapsed lung had pulmonary fibrosis and did not reexpand at all because of reduced pulmonary compliance.

[Effect of intravenous administration of coagulation factor XIII concentrate on persistent pleural air leak]

We administered coagulation factor XIII concentrate intravenously to six patients suffering from persistent air leak with no evidence of bronchopleural fistulae They are those who had either failed to be healed in response to pleurodesis, intrapleural fibrin glue injection and surgery or had not received such treatment. Their blood coagulation factor XIII activity levels were less than 70% of the standard plasma level. In four of the six patients, air leak stopped within 10 days after the treatment begun. Because factor XIII plays an important role in wound healing, reduction in the activity level can be a cause of insufficient healing of pulmonary surface fistulae and may lead to persistent air leak. In such cases, intravenous administration of factor XIII concentrate increases the activity levels and may put an end to persistent air leak.

[Respiratory surgery through a median sternotomy utilizing the IMA-retractor]

A new utilization of the IMA-retractor for respiratory surgery is described. Following linear division of the sternum, the IMA-retractor is applied to tip upward the sternal edge on the operated side. The IMA-retractor provides excellent exposure of the lung without the need for surgical assistance and greatly facilitates respiratory operations through the median sternotomy.

Radiosensitivity of skin fibroblasts from atomic bomb survivors with and without breast cancer

Fibroblasts were established in vitro from skin biopsies obtained from 55 women and 1 man with or without breast cancer and with or without exposure to radiation from the atomic bomb explosion in Hiroshima. The radiosensitivity of these cells was evaluated by clonogenic assays after exposure to X-rays or to fission neutrons from a 252Cf source. Data were fitted to a multitarget model, S/S0 = A [1 - (1 - ekD)N], for both X-ray and neutron dose-survival curves. A single hit model, S/S0 = AekD, fits the neutron dose-survival responses as well. There were no differences in the means or variances of radiosensitivity between exposed and nonexposed groups or between patients with or without breast cancer. Hence, although the sample is not large, it provides no support for the hypothesis that atomic bomb radiation preferentially induces breast cancer in women whose cells in vitro are sensitive to cell killing by radiation.

A case of patent ductus arteriosus in an 80 years old woman

A case of patent ductus arteriosus (PDA) in an 80 years old female is presented. This is the oldest case reported in Japan and the most elderly case of newly diagnosed PDA in the world. Features of PDA in the elderly are reviewed.

Calcium-activated neutral protease inhibitor (E-64c) and reperfusion for experimental myocardial infarction

We examined the efficacy of the combination of coronary reperfusion and calcium-activated neutral protease (CANP) inhibitor (E-64c) for the treatment of acute myocardial infarction in dogs. In 34 dogs, the left anterior descending artery (LAD) was occluded and reperfused after 1 hour (Groups A and B). In the remaining 49 dogs, the LAD was ligated (Groups C and D). E-64c (100 mg/kg, Groups A and C) or vehicle (Groups B and D) was injected intravenously before and after the coronary occlusion or ligation. After 24 hours the hearts were removed. The proportion of the infarct size in the LAD perfusing area (risk zone) in Group A was 47.3 +/- 9.7%, significantly lower than in Group C (54.8 +/- 8.2%, p less than 0.05) or Group D (58.7 +/- 10.0%, p less than 0.01). There was a significant difference between Group B (52.9 +/- 8.6%) and Group D as well (p less than 0.05). The effects of reperfusion (p = 0.0016) and E-64c (p = 0.0226) per se on infarct size were significant, but the combination of reperfusion and E-64c was not additive. The decrease in CPK activity in the risk zone was significantly lower in the reperfused group (p = 0.0001). The mCANP activity was higher in the border zone and lower in the infarct zone. The trend in the mu CANP activity was similar to that of mCANP. Thus, treatment with a CANP inhibitor in the early phase of acute myocardial infarction may be marginally beneficial in combination with reperfusion.

[Clinical evaluation of the prehospital phase of acute myocardial infarction in the elderly]

In order to clarify the clinical characteristics of the prehospital phase of acute myocardial infarction (AMI) in the elderly, we studied 92 elderly (65 years old or more) and 41 younger patients with first AMI. Fifty eight elderly (63.1%) and 30 younger (72.7%) patients had typical symptoms such as chest pain at onset. There were 5 elderly cases who had no symptom, although all of the younger had some symptoms at onset. More than 70% of the younger cases developed their symptoms either between 6 am and noon or between 6 pm and midnight, whereas the elderly showed no such tendency. Intervals between the onset of symptoms and hospital admission (admission time) averaged 6.8 hours (hr) in the younger and 7.7 hr in the elderly. Approximately one half of the elderly and a quarter of the younger showed admission time more than 6 hr, respectively. Elderly cases with atypical symptoms tended to have a longer admission time than younger cases (7.2 vs 3.1 hr), although there was no significant difference between the elderly and the younger with typical symptoms (8.0 vs 7.9 hr). Younger patients with heart failure had significantly shorter admission time than those without heart failure (3.6 vs 8.6 hr). However, the elderly with heart failure showed a prolonged admission time (6.1 hr). Although there was no difference on admission time between survivors and non-survivors within 28 days after admission in the elderly (7.5 vs 8.4 hr), the elderly non-survivors with atypical symptoms had the longest admission time (13.0 hr).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical evaluation of the plasma levels of immunoreactive atrial natriuretic peptide in elderly patients with heart diseases

Plasma levels of immunoreactive atrial natriuretic peptide (ANP) were estimated in 69 elderly patients over 60 years of age (mean 76.4 years) with or without heart diseases and in ten young, healthy volunteers (mean 33.0 years) to evaluate the clinical significance of ANP in the elderly. Plasma ANP levels in nine patients without heart diseases were significantly (P less than .01) higher than in the ten young, healthy subjects (mean +/- SD, 46.0 +/- 22.0 vs 22.1 +/- 6.3 pg/mL) and a significant positive correlation was observed between ANP level and age in these subjects (r = 0.60, P less than 0.01). Plasma ANP levels in 60 patients with heart diseases (158.4 +/- 158.5 pg/mL) were significantly (P less than 0.05) greater than in nine patients without heart diseases. Plasma ANP levels in patients with congestive heart failure or atrial fibrillation were 285.8 +/- 185.2 or 223.0 +/- 185.9 pg/mL, respectively; each of these values was significantly (P less than 0.01) higher than in patients without heart diseases. In three patients with paroxysmal atrial fibrillation, plasma ANP levels during atrial fibrillation were three times greater than when atrial fibrillation returned to normal sinus rhythm (377.3 +/- 78.5 vs 101.1 +/- 68.5 pg/mL). These results indicate that plasma ANP levels increase with advancing age, and that increased ANP levels are associated with various heart diseases in elderly subjects, possibly through stretch of the atrial wall.

A histopathologic study of the conduction system in an elderly patient with partial atrial standstill

Electrophysiologic and histopathologic studies were performed on an 83-year-old man with partial atrial standstill. In the electrophysiologic study, no atrial electrical activity was recorded in the right atrium, but f waves were seen in the coronary sinus electrogram. Although the high right atrium and the atrial septum could not be activated by electrical stimuli of up to 10 V, the low atrium could be stimulated. The pathologic examination showed that there was extensive fatty infiltration into the sinus node and fibrosis in the atrial muscle. In the low right atrium, the musculature was partially preserved.

Incidence of female breast cancer among atomic bomb survivors, Hiroshima and Nagasaki, 1950-1980

Ascertainment of breast cancer incidence among the cohort of the RERF Life Span Study extended sample identified 574 breast cancers among 564 cases diagnosed during 1950-1980 of which 412 cancers were reviewed microscopically. There were no dose-dependent differences with respect to diagnostic certainty or histological type. As in previous studies, the dose response appeared to be roughly linear and did not differ between the two cities. The most remarkable new finding was the emergence of a radiation-related excess among women under 10 years of age at exposure. The risk of radiogenic breast cancer appears to decrease with increasing age at exposure, whether expressed in relative or absolute terms. These results suggest that exposure of female breast tissue to ionizing radiation at any time during the first four decades of life, even during the premature stage, can cause breast cancer later in life, and that the length of time that tumor promoters such as endogenous hormones operate following exposure has an important influence on the development of radiation-induced breast cancer. An unresolved question is whether breast cancer risk is increased by radiation exposure at ages older than 40.

Comparison of enzymatic, anatomic and electrocardiographic estimates of myocardial infarct size in man

Myocardial infarct size is definitely related to cardiac function and prognosis. For a critical evaluation of infarct size estimation methods, we weighed infarcted myocardium from 44 autopsy cases (24 men and 20 women, mean age of 76.8 yr.), and compared the weight with the peak value of serum CPK activity (peak-CPK), the peak value of serum CPKMB isoenzyme activity (peak-CPKMB), the total CPK release (sigma CPK), and the QRS scoring system in the standard 12-lead electrocardiogram (ECG) modified by Wagner et al.. The mean infarcted myocardial weight (MI weight) of the 44 cases was 38.4 g. The mean value of the peak-CPK, peak-CPKMB, and sigma CPK were 2487, 221, and 4597 IU/ml, respectively, and the mean QRS point score was 7.2. The interval between serial CPK determination and ECG recording or autopsy averaged 130.1 or 52.4 days, respectively. There were significant (p less than 0.01) correlations between the MI weight and peak-CPK (r = 0.63, n = 17), peak-CPKMB (r = 0.79, n = 17), sigma CPK (r = 0.72, n = 11), and the QRS scoring system (r = 0.64, n = 39), respectively. Especially in cases of non-transmural myocardial infarction, the QRS scoring system showed a high correlation with MI weight (r = 0.82, n = 11, p less than 0.01). We conclude that the peak-CPK, peak-CPKMB, sigma CPK, and the QRS scoring system are useful for the estimation of myocardial infarct size.

Comparison of radiosensitivities of human autologous normal and neoplastic thyroid epithelial cells

Studies were conducted to examine differences between the radiosensitivities of normal and neoplastic epithelial cells of the human thyroid. Freshly excised thyroid tissues from the tumours of eight patients with papillary carcinoma (PC) and five with follicular adenoma (FA) were cultured in vitro separately from normal thyroid tissue obtained from the surgical margins of the same patients. Plating efficiency of unirradiated control tissue was lower, on average for tumour tissue compared with normal tissue. Radiosensitivity, measured by the 37% inactivation dose D0, was greater for carcinoma tissue than for normal tissue in seven out of eight PC cases. Adenomatous tissue was less radiosensitive than normal tissue in four out of five FA cases. This is the first report comparing the radiosensitivity of autologous normal and abnormal epithelial tissue from the human thyroid.

[Interaction of proteases and their inhibitors in the pathogenesis of pancreatitis]

It was confirmed that esterolytic activity was significantly elevated in plasma of patients with acute pancreatitis, which correlated better with the stage of the disease than serum amylase level. Using the several column chromatography procedures, pancreatic kallikrein, trypsin and pancreatic elastase were separated and purified from alpha 2-macroglobulin (alpha 2-M) fractions of patients plasma with acute pancreatitis. From this this result, it was confirmed that kallikrein was liberated into the blood stream from the pancreas during attacks of acute pancreatitis and the liberated kallikrein combined with alpha 2-M. Furthermore, the coexistence of trypsin is required for the complex formation of alpha 2-M and pancreatic kallikrein. It was speculated that alpha 2-M might be decomposed by the excessive amount of elastase, and consequently, might release all of its combining enzymes into the blood stream. In the present study, the activation mechanism of fibrinolytic enzyme system in plasma by human pancreatic elastase was investigated. Elastase not only converted the co-existing plasminogen to low molecular weight plasminogen which could be easily activated by the activators, but also inhibited alpha 2-M and alpha 2-plasmin inhibitor, and consequently, induced the activation of the fibrinolytic enzyme system in plasma. Furthermore, it was also confirmed that elastase could activate plasma kallikreinogen to kallikrein.