Clinical and angiographic outcomes following percutaneous treatment of non-occlusive vs. chronically total occluded coronary lesions

Background

Recent advancements in recanalization techniques, introduction of dedicated equipment and elaboration of systematic algorithmic approaches have significantly improved procedural success of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedures. However, despite their undisputable merits in terms of procedural success, direct comparisons of mid-term clinical and angiographic outcomes following CTO and non-CTO-PCI are missing.

Purpose

The aim of this study was to assess the clinical and angiographic outcomes of patients undergoing successful CTO-PCI as compared to a propensity matched cohort of patients undergoing PCI of non-occlusive coronary lesions.

Methods

All consecutive patients undergoing successful CTO recanalization procedures at our center between 2015 and 2018 were included (N=453; 472 lesions). For matching purposes, all patients undergoing non-CTO-PCI present in our database were included (N=14733; 23458 lesions). A 1-to-1 nearest neighbour matching using baseline clinical and angiographic variables was performed to identify one patient undergoing non-CTO-PCI (N=453; 472 vessels) for each patient undergoing CTO-PCI (N=453; 472 vessels). Surveillance angiography was scheduled at 6–9 months and clinical follow-up was performed up to 12 months. The primary clinical endpoint of interest was the incidence of major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction (MI) and target lesion revascularization (TLR). The secondary angiographic endpoint was in-segment binary restenosis.

Results

Patients undergoing CTO-PCI displayed a tendency towards higher degrees of binary restenosis at surveillance angiography as compared to those undergoing non-CTO-PCI (CTO vs. non-CTO: 30.5% vs. 24.0%; P=0.058), despite not meeting statistical significance. Of note, the incidence of occlusive restenosis was low and comparable between groups (2.2% vs. 1.4%; P=0.603). At 12 months follow-up, MACE occurred in 83 patients (19.7%) in the CTO-PCI and 59 patients (14.1%) in the non-CTO-PCI group (hazard ratio [HR] = 1.44; 95% confidence interval [CI]: 1.03–2.01; P=0.033). TLR rates were significantly higher following CTO- as compared to non-CTO-PCI (17.2% vs. 10.3%; HR=1.72 [1.18–2.51], P=0.005). The incidence of all-cause death (2.6% vs. 3.3%; P=0.548) and MI (0.5% vs. 1.4%; P=0.177) was not significantly different between the groups.

Conclusion

In this large, propensity-matched comparison of clinical and angiographic outcomes following CTO- vs. non-CTO-PCI, we found CTO-PCI to be associated with a higher MACE rate at 12 months, primarily driven by significantly higher TLR rates. The incidence of occlusive restenosis was low and comparable between groups.

Funding Acknowledgement

Type of funding sources: None.

Combined pre- and post-capillary pulmonary hypertension defined by new criteria is worse prognosis group in patients with heart failure

Background

The 6th World Symposium on Pulmonary Hypertension suggested major revision about definition of pulmonary hypertension (PH) as mean pulmonary artery pressure (mPAP) >20 mmHg. The definitions of two subsets of PH due to left heart disease (PH-LHD) also revised. The aim of this study was to investigate clinical characteristics and outcomes of subsets of PH-LHD defined by new criteria.

Methods

We analyzed 701 patients admitted for symptomatic heart failure (NYHA ≥2) and underwent right heart catheterization at compensated stage between 2007 and 2016. These patients were divided into 4 groups as follows: (i) Isolated post-capillary PH (Ipc-PH); mPAP >20 mmHg and pulmonary artery wedge pressure (PAWP) >15 mmHg and pulmonary vascular resistance (PVR) <3 WU, (ii) Combined pre- and post-capillary PH (Cpc-PH); mPAP >20 mmHg and PAWP >15 mmHg and PVR ≥3 WU, (iii) pre-capillary PH; mPAP >20 mmHg and PAWP ≤15 mmHg, (iv) no PH; mPAP ≤20 mmHg. Kaplan-Meier curves were applied to investigate whether each groups predict heart failure (HF) death or HF readmission.

Results

The study patients were divided into Ipc-PH (n=268), Cpc-PH (n=54), Pre-capillary PH (n=112), and no PH (n=267). Cpc-PH was significantly associated with HF death or HF readmission as compared to other groups (Figure).

Conclusions

Cpc-PH defined by new criteria was significantly associated with poor long-term clinical outcomes, which suggests new criteria of two subsets of PH-LHD could be strict risk stratification for symptomatic heart failure.

Figure1. Kaplan-Meier curves.

Funding Acknowledgement

Type of funding source: None

P5504Comparison of in-hospital clinical outcomes of acute myocardial infarction between nonagenarians and octogenarians: a propensity-score matched analysis

Background

Acute myocardial infarction (AMI) in the very elderly is associated with high morbidity and mortality. Because the majority of study population in clinical researches focusing on the very elderly with AMI were octogenarians, clinical evidences regarding AMI in nonagenarians are sparse. The aim of the present study was to compare in-hospital clinical outcomes of AMI between octogenarians and nonagenarians.

Methods

We included consecutive 415 very elderly (≥80 years) patients with AMI, and divided into the nonagenarian group (n=38) and the octogenarian group (n=377). Clinical characteristics and in-hospital outcomes were compared between the 2 groups. Furthermore, we used propensity-score matching to find the matched octogenarian group (n=38).

Results

Percutaneous coronary interventions (PCI) to the culprit of AMI were similarly performed between the nonagenarian (86.8%) and octogenarian (87.0%) groups The incidence of in-hospital death in the nonagenarian group (13.2%) was similar to that in the octogenarian group (14.6%) (P=0.811). The length of hospital stay was significantly shorter in the nonagenarian group (7.4±4.2 days) than that in the octogenarian group (15.4±19.4 days) (P<0.001). After using the propensity-score matching, the incidence of in-hospital death was less in the nonagenarian group (13.2%) than in the matched octogenarian group (21.1%) without reaching statistical significance (P=0.361). The length of hospitalization was significantly shorter in the nonagenarian group (7.4±4.2 days) than in the matched octogenarian group (17.8±37.0 days) (P=0.01).

Clinical outcomes Nonagenarian group (n=38) Octogenarian group (n=377) P value In-hospital death, n (%) 5 (13.2) 55 (14.6) 0.811 Length of hospital stay (days) 7.4±4.2 15.4±19.4 <0.001 Length of CCU stay (days) 3.3±2.5 4.7±5.1 0.109 LVEF (%) 48.2±9.2 50.8±13.7 0.152 Peak CPK (U/L) 1424.8±1580.8 1640.1±2394.4 0.912 CCU indicates Coronary care unit; LVEF, Left ventricular ejection fraction; CPK, Creatine kinase.

Flow-chart

Conclusions

The in-hospital mortality of nonagenarians with AMI was comparable to that of octogenarians with AMI. In-hospital outcomes in nonagenarians with AMI may be acceptable as long as acute medical management including PCI to the culprit of AMI is performed.

Acknowledgement/Funding

None

Factors controlling denitrification of mudflat sediments in Ariake Bay, Japan

To investigate the seasonal variation of denitrification rate (DR) and clarify the controlling factors of denitrification in the mudflat sediments of Ariake Bay, we conducted field surveys biweekly each month from April 2006 to January 2008. NH4(+)-N porewater concentration increased from summer to autumn due to the organic material mineralization under higher sediment temperatures. The seasonal pattern of NH4 (+)-N flux between sediments and overlying water interface indicated that the mudflat sediments were a source of NH4(+)-N in summer. NO3(-)+NO2(-)-N porewater concentrations were low, ranging from 0.53 to 11.46 μM, and mudflat sediments were sinks of NO3(-)+NO2(-)-N throughout the year. The mean number of denitrifiers tended to increase in July-September (2188-75,057 MPN g(-1)) and to decrease in March-May (500-3740 MPN g(-1)). DR tended to increase in summer, ranging from 76.03 to 990.21 μmol m(-2) day(-1), and to decrease in winter, ranging from 25.01 to 206.07 μmol m(-2) day(-1). There was no significant correlation between DR and denitrifier number. Environmental factors influencing DR during the investigation period were determined by multiple regression analysis with the stepwise method. The results indicated that NO3(-)+NO2(-)-N flux was an important factor in denitrification of mudflat sediments in Ariake Bay. Denitrification was depended on nitrate diffusing from overlying water into sediments under reduced sediment conditions during summer-mid-autumn. On the other hand, in late autumn-winter at Eh>+200 mV and sediment temperature >10 °C, nitrate produced by sediment nitrification was thought to be denitrified subsequently; that is, the coupled nitrification-denitrification may have taken place in the upper layer of mudflat sediments.

HBV-related fulminant hepatic failure: successful intensive medical therapy in a candidate for liver transplantation

Fulminant hepatic failure (FHF) usually has a fatal prognosis without liver transplantation. We describe the case of a woman who developed FHF, and was evaluated as a candidate for liver transplantation, but who was cured without transplantation through intensive medical care that included glucagon-insulin therapy, methylprednisolone pulse therapy, interferon beta and lamivudine administration, cyclosporine administration, and high-volume hemodiafiltration and plasma exchange. In a patient with FHF who is a candidate for liver transplantation but for whom the transplantation cannot be performed for some reason, intensive medical therapy, including regeneration-promoting therapy, immunosuppressive therapy, antiviral therapy, and vigorous hepatic support, should be carried out.

Gadolinium-enhanced MR angiography in the evaluation of congenital cardiovascular disease pre- and postoperative states in infants and children

The purpose of this study was to evaluate the utility of dynamic contrast magnetic resonance (MR) angiography under sedation for assessing congenital cardiovascular disease in infants and small children before and after cardiac surgery. In 38 patients with cardiovascular abnormalities, thoracic vasculatures were evaluated in either the preoperative (group 1; 23 patients, median age 9 months old) or the postoperative (group 2; 15 patients median age 1. 3 years old) state using gadolinium-enhanced dynamic MR angiography. Acquired data were processed with a multiprojection volume reconstruction. Image quality (grades 1-5, undiagnostic to excellent), presence or absence of the extracardiac vasculature, its pathology (group 1), and the patency of the postsurgical shunt or reconstructed vasculature (group 2) were evaluated. All images were of diagnostic image quality (mean grade 4.4-3.2). Recognition of the thoracic vasculature was correctly made in all cases (38/38, 100%). In group 1, anomalies and pathologic changes were correctly identified in 22 of 23 cases (95.7%). In one patient with dextrocardia and the cardiac type of total anomalous pulmonary venous return, the abnormality was not recognized. In group 2, the patency of the shunt flow after Glenn (n = 6), modified Fontan (n = 4), Rastelli (n = 1), and Blalock-Taussig (n = 3) operations was well demonstrated in each case. The reconstructed pulmonary artery (n = 1), veins (n = 2), and aorta (n = 1) were correctly visualized. In one case, stenosis of the reconstructed left pulmonary vein was missed by MR angiography. In 14 of 15 cases in group 2 (93.3%), MR angiography correctly gave information on the operated areas. In conclusion, dynamic contrast MR angiography under sedation is useful for evaluation of the thoracic vasculature of infants and small children in the pre- and postoperative states. J. Magn. Reson. Imaging 2000;12:1034-1042.

Mixed connective tissue disease with multiple organ damage: successful treatment with plasmapheresis

A 24-year-old-woman with mixed connective tissue disease (MCTD) developed multiple organ failure, disseminated intravascular coagulation (DIC), metabolic acidosis, and respiratory and renal failure resulting from visceral vasospasm, so-called visceral Raynaud's phenomenon. After plasmapheresis, the condition of multiple organ failure was markedly improved. The successful treatment with plasmapheresis was dependent upon the removal of immune complexes in serum and improvement of visceral circulation. Thus plasma exchange is recommended as a possible a treatment for multiple organ damage in MCTD.

Gadolinium-enhanced MR angiography in the evaluation of congenital cardiovascular disease pre- and postoperative states in infants and children

The purpose of this study was to evaluate the utility of dynamic contrast magnetic resonance (MR) angiography under sedation for assessing congenital cardiovascular disease in infants and small children before and after cardiac surgery. In 38 patients with cardiovascular abnormalities, thoracic vasculatures were evaluated in either the preoperative (group 1; 23 patients, median age 9 months old) or the postoperative (group 2; 15 patients median age 1. 3 years old) state using gadolinium-enhanced dynamic MR angiography. Acquired data were processed with a multiprojection volume reconstruction. Image quality (grades 1-5, undiagnostic to excellent), presence or absence of the extracardiac vasculature, its pathology (group 1), and the patency of the postsurgical shunt or reconstructed vasculature (group 2) were evaluated. All images were of diagnostic image quality (mean grade 4.4-3.2). Recognition of the thoracic vasculature was correctly made in all cases (38/38, 100%). In group 1, anomalies and pathologic changes were correctly identified in 22 of 23 cases (95.7%). In one patient with dextrocardia and the cardiac type of total anomalous pulmonary venous return, the abnormality was not recognized. In group 2, the patency of the shunt flow after Glenn (n = 6), modified Fontan (n = 4), Rastelli (n = 1), and Blalock-Taussig (n = 3) operations was well demonstrated in each case. The reconstructed pulmonary artery (n = 1), veins (n = 2), and aorta (n = 1) were correctly visualized. In one case, stenosis of the reconstructed left pulmonary vein was missed by MR angiography. In 14 of 15 cases in group 2 (93.3%), MR angiography correctly gave information on the operated areas. In conclusion, dynamic contrast MR angiography under sedation is useful for evaluation of the thoracic vasculature of infants and small children in the pre- and postoperative states. J. Magn. Reson. Imaging 2000;12:1034-1042.

[A case of total cavopulmonary connection by utilization of coronary sinus as a hepatic venous return]

A 2-year-old boy with polysplenia, double outlet right ventricle after pulmonary banding and unilateral bidirectional shunt was operated on. A modified total cavopulmonary connection was done by utilization of coronary sinus as a retrograde route for the hepatic venous return. Left SVC was transected and its distal end was anastomosed to the left pulmonary artery after PA angioplasty. An equine pericardial patch was placed over the ostia of the hepatic vein and coronary sinus. Two ostia of the coronary veins were excluded from the created route. The proximal end of the left SVC was anastomosed to the inferior side of the left pulmonary artery. Postoperative course was uneventful. The postoperative angiogram showed smooth hepatic venous return through the coronary sinus and no pressure gradient was recorded between hepatic vein and pulmonary artery.

Pulmonary stenosis in recipient twins in twin-to-twin transfusion syndrome: report on 3 cases and review of literature

This report describes 3 cases of pulmonary stenosis in the recipient twin in twin-twin transfusion syndrome. Fetal echocardiography showed cardiomegaly, tricuspid valve regurgitation, and increased reverse flow in the inferior vena cava, as signs of congestive heart failure in all 3 cases. We diagnosed 2 cases of pulmonary stenosis by fetal echocardiography prenatally and confirmed our findings in all 3 cases postnatally. Two cases underwent postnatal balloon valvuloplasty to release the pulmonary valvular stenosis in neonatal period. The third one died soon after delivery and autopsy showed a slightly thickened pulmonary valve. One of the cases was diagnosed in the early second trimester (20 weeks of pregnancy), the earliest detection of fetal pulmonary stenosis reported in literature. The presence of high peak velocity of the pulmonary artery at 20 weeks of pregnancy preceded the development of pulmonary stenosis in this case. This supports the hypothesis that alterations in fetal hemodynamics may result in structural cardiac abnormality.

Neonatal periventricular leukomalacia preceded by fetal periventricular echodensity

OBJECTIVE

The purpose of this prospective study is to verify whether fetal periventricular echodensity (PVE) precedes neonatal periventricular leukomalacia (PVL).

METHODS

Fetal brains were studied with transvaginal scan in 63 high-risk fetuses from 17 to 32 weeks of pregnancy, PVE echogenicity was quantified with ultrasonic histogram, and neonatal brains and clinical courses were studied after birth.

RESULTS

No fetal cystic PVL was found, instead, fetal PVE was detected in 42 fetuses. The quantified echogenicity value was higher in PVE than in normal brain. Four cases developed neonatal PVL among 28 preterm and 1 among 14 term births. Neonatal PVL developed in the 23 cases of persistent fetal PVE, whereas no neonatal PVL was found when fetal PVE was negative or disappeared. Cord compression signs were common in PVL cases.

CONCLUSION

Neonatal PVL was preceded by antepartum persistent fetal PVE in the present study.

[A case of repeated surgical intervention for pulmonary venous obstruction after repair of total anomalous pulmonary venous connection]

A 3-month-old boy showed pulmonary venous obstruction after repair of total anomalous pulmonary venous connection. He was treated with a novel method of stureless in situ pericardium repair. Six weeks after this operation, he showed recurrence of venous obstruction and the same procedure was performed. Another six weeks after this operation, stenosis of the left pulmonary vein necessitated the same procedure again. Although he suffered from pneumonia and died of sepsis, this procedure revealed effectiveness for at least three months. This report showed clinical course after repeated stureless in situ pericardium repair. More experience will be necessary to evaluate the effectiveness of this procedure.

Pulmonary hypertension associated with pulmonary occlusive vasculopathy after allogeneic bone marrow transplantation

BACKGROUND

Pulmonary vasculature abnormalities, including pulmonary veno-occlusive disease, have been demonstrated in marrow allograft recipients. However, it is often difficult to make a correct diagnosis of pulmonary lesions.

METHODS

An open lung biopsy was performed on a patient who developed severe pulmonary hypertension after bone marrow transplantation for T-cell lymphoma.

RESULTS

An open lung biopsy specimen demonstrated pulmonary arterial occlusion due to intimal fibrosis and veno-occlusion. The most striking alteration was partial to complete occlusion of the small arteries by fibrous proliferation of the intima.

CONCLUSION

High-dose preparative chemotherapy and radiation before transplantation are thought to have contributed to the development of vasculopathy in this patient, because arterial occlusion by intimal fibrosis and atypical veno-occlusion are often associated with lung injury due to chemoradiation. An open lung biopsy is essential for diagnosing pulmonary vascular disease presenting signs compatible with posttransplantation pulmonary hypertension.

Pathologic finding of restenosis in stent-implemented right ventricle-pulmonary artery extracardiac conduit

We describe an excised specimen of a stent-implanted valved equine pericardial extracardiac conduit in the right heart. It appears from careful pathologic examination that the stent acted as a nidus for thrombus formation followed by thick neo-intimal development over the stent, which caused restenosis. Restenosis occurred despite anticoagulation.

Heat-induced drug resistance is associated with increased expression of Bcl-2 in HL60

HL60 cells underwent apoptosis with heat treatment, i.e. exposure to 42 degrees C for 120 minutes. Cells exposed to the same temperature for 30 minutes became resistant to subsequent, otherwise lethal, heat shock. These thermotolerant cells also acquired resistance to anti-cancer drugs including daunorubicin and VP16. We found that mild heat shock upregulates not only HSP70 but also BCL-2, though BCL-2 has not previously been recognized as a heat-inducible protein. Expression of BCL-2 closely paralleled resistance to subsequent exposure to anticancer drugs. The present results suggest that BCL-2 may play a role in heat-induced drug resistance.

Thromboembolism originated from the pulmonary artery stump after Fontan operation

Cerebral thromboembolism is a rare but serious complication after Fontan operation. This is the report of a patient who underwent a successful intracardiac thrombectomy for cerebral thromboembolism after Fontan operation. A 2-year-old girl was referred to us with the diagnosis of tricuspid atresia without pulmonary stenosis, normally related great arteries, and a ventricular septal defect. Although she underwent a successful Fontan operation and division of the main pulmonary artery, she developed a cerebrovascular event at 3 weeks after the operation. Echocardiography demonstrated a large thrombus within the residue of the main pulmonary artery, and suggested that the thrombus had migrated into the systemic circulation by way of the ventricular septal defect. At 2 weeks after the cerebrovascular event, she underwent thrombectomy and excision of the pulmonary valve. Although she has developed slight left-sided hemiparesis, she is leading a normal life at 1 year after the operation.

Clinical features of isolated noncompaction of the ventricular myocardium: long-term clinical course, hemodynamic properties, and genetic background

OBJECTIVES

A nationwide survey was conducted to clarify the clinical features of isolated noncompaction of the ventricular myocardium (INVM) in Japanese children in comparison with features previously described in patients with INVM.

BACKGROUND

Isolated noncompaction of the ventricular myocardium is a rare disorder characterized by an excessively prominent trabecular meshwork. It is accompanied by depressed ventricular function, systemic embolism and ventricular arrhythmia.

METHODS

A questionnaire specifically designed for this study was sent to 150 hospitals in Japan where a pediatric cardiology division exists.

RESULTS

Twenty-seven patients were diagnosed by two-dimensional echocardiography, their ages ranging from one week to 15 years at presentation, with follow-up lasting as long as 17 years. The gross anatomical appearance and the extension of noncompacted myocardium predominantly at the apex observed on two-dimensional echocardiograms were similar to observations reported previously. Dissimilarities included a greater number of asymptomatic patients at initial presentation, a longer clinical course with gradually depressed left ventricular function, no systemic embolism, and rare ventricular tachycardia in the Japanese children. Cardiac catheterization disclosed normal left ventricular end-diastolic volume and increased left ventricular end-diastolic pressure in most cases, consistent with restrictive hemodynamics. A higher incidence of Wolff-Parkinson-White syndrome was found in the children, whereas left bundle branch block was rarer than reported in adults. Familial recurrence was high (44%) and included many women.

CONCLUSIONS

In Japanese children, INVM can be found by screening examinations at asymptomatic stage, and it might have a longer dinical course with gradually depressed left ventricular function and restrictive hemodynamics. The pattern of familial recurrence we observed implies that INVM is a distinctive clinical entity with a heterogeneous genetic background.

Further evidence suggesting a limited role of digitalis in infants with circulatory congestion secondary to large ventricular septal defect

In infants with a large ventricular septal defect, the acute hemodynamic effect of intravenous digitalis varies depending on baseline systemic and pulmonary resistance. Digitalis may act adversely by increasing pulmonary blood flow with an elevation in left atrial pressure in severely congested infants with ventricular septal defects.

OKT3 therapy for transfusion-associated graft-versus-host disease in a neonate

Transfusion-associated graft-versus-host disease (TA-GVHD) is a fatal side effect of blood transfusion. The present study describes a case of TA-GVHD in a neonate treated with anti-CD3 monoclonal antibody (OKT3). The patient died of systemic bacterial infection. However, it is suggested that OKT3 suppressed the graft-versus-host reaction due to the improvement in the clinical signs and a change in the human leucocyte antigen (HLA) type on the surface of circulating lymphocytes. A relatively large dose of OKT3 together with steroid pulse therapy and cyclosporin A may be required for the control of TA-GVHD in neonates.

Pulmonary hypertension in patients with complete transposition of the great arteries: midterm results after surgery

Postoperative results of surgical repair of complete transposition of the great arteries (TGA) with pulmonary hypertension (PH) in 19 patients in whom mean pulmonary arterial pressure was >50 mmHg or the pulmonary/systemic arterial pressure ratio was >0.8 were examined. TGA with intact ventricular septum was diagnosed in 10 patients and TGA with ventricular septal defect in 9. At the time of corrective surgery (arterial switch 10, atrial switch 9), patients ranged in age from 7 months to 14 years (mean 2.4 years). Seventeen patients (89%) survived with New York Heart Association functional class I. Seven patients in whom calculated pulmonary vascular resistance was 10-20 U m2 after surgery survived with subsequent regression of PH. Residual PH was diagnosed in 36% of survivors. Two patients in whom pulmonary vascular resistance was 26 and 36 U m2, respectively, died after surgery. In patients with TGA, severe PH was not necessarily fatal and was potentially reversible after successful surgery.

Effects of activin A/erythroid differentiation factor on erythroid and megakaryocytic differentiations of mouse erythroleukemia (Friend) cells: evidence for two distinct modes of cell response

To further characterize activin A/erythroid differentiation factor (EDF) action on hematopoietic cell differentiation, we examined the effects of activin A/EDF on megakaryocytic and erythroid differentiation by determining acetylcholinesterase (AchE) activity and hemoglobin production in the mouse erythroleukemia (MEL) cell line F55. Activin A/EDF induced AchE activity of F55 cells in a dose-dependent manner. Erythroid differentiation of F55 cells, which was characterized by an increase in dianisidine-positive cells, was also induced by activin A/EDF. The effect of activin A/EDF on hemoglobin synthesis appeared more slowly compared with the effect on AchE activity. Erythroid differentiation induced by activin A/EDF was affected by the initial cell density, but AchE activity was not. Sodium orthovanadate, a tyrosine phosphatase inhibitor, markedly inhibited activin A/EDF-induced erythroid differentiation but not activin A/EDF-induced AchE activity. Other erythroid differentiation inducers, sodium butyrate and butyrylcholine chloride, mildly increased AchE activity in F55 cells, but N,N'-hexamethylene-bis-acetamide (HMBA), dimethyl sulfoxide (DMSO), and genistein did not. Dexamethasone inhibited HMBA-induced erythroid differentiation but did not affect activin A/EDF or sodium butyrate action. These results suggest that F55 cells potentially can differentiate into cells of a megakaryocytic lineage in addition to an erythroid lineage, and that activin A/EDF further potentiates the cell differentiation of this cell line. In addition, our results suggest that the mode of activin A/EDF effects on megakaryocytic differentiation is distinct from that on erythroid differentiation.

Induction of ICAM-1 expression on the eosinophilic leukemia cell line-3 (EoL-3) by platelet-activating factor and platelet factor 4

BACKGROUND

Eosinophils are assumed to transmigrate to local tissue under the direction of the eosinophil chemotactic factor present in allergic inflammatory lesions.

OBJECTIVE

We examined whether PAF and PF4, which are related to eosinophil localization, affect the expression of ICAM-1 on the human eosinophilic leukemia cell line (EoL-3).

METHODS

ICAM-1 expression on EoL-3 cells in the presence or absence of PAF or PF4 was assessed by immunofluorescent analysis. The presence of sICAM-1 in culture supernatants of EoL-3 cells was detected with an ELISA kit.

RESULTS

Both PAF and PF4 enhanced the expression of ICAM-1 on EoL-3 cells. We found no difference in sICAM-1 concentration with or without PAF or PF4.

CONCLUSIONS

The eosinophil chemotactic factors PAF and PF4 not only may attract eosinophils, but they may enhance the expression of ICAM-1 on eosinophils at the site of the lesion. Further, it is suggested that the shedding of ICAM-1 has little relation to the induction of ICAM-1 expression in vitro.

1.4-kW Nd:YAG slab laser with a diffusive closed-coupled pump cavity

A high-power high-efficiency Nd:YAG slab laser with lamp pumping is developed by use of a novel diffusive-closed coupled lamp pump cavity. In cw-mode operation, 1.45 kW of output power is obtained with a slope efficiency of 5.0%. In pulsed-mode operation (50 pulses/s, 25% pulse duty), 1.4 kW of output power is obtained with a slope efficiency of 4.3%. The output power per unit volume is 45 W/cm(3). To our knowledge, these output powers and the power per unit volume are the highest obtained for the single-head Nd:YAG slab laser with lamp pumping.

[Characterization of expression of adhesion molecules on eosinophils in bronchial asthma]

It is well known that inflammatory processes play an important role in allergic reactions such as bronchial asthma (BA). Eosinophils are considered to the main players in such allergic inflammation. Moreover, adhesion molecules have recently been found to play an important role in the inflammatory processes in allergic and immune reactions. Thus, in this study, the characteristics of the adhesion molecules expression on human eosinophils obtained from BA patients were examined. High intensity expressions of adhesion molecules (CR3, LFA-1 alpha, LFA-1 beta) on eosinophils obtained from the patients were observed. Furthermore, ICAM-1, which is the ligand for LFA-1 molecules, was also expressed on eosinophils from BA patients. To extend our understanding of this high intensity expression of adhesion molecules (CR3, LFA-1 alpha, LFA-1 beta, ICAM-1) on such eosinophils, we examined whether chemotactic agents might be involved in adhesion molecule expression using an eosinophilic cell line named EoL-3. These characteristics of adhesion molecules on eosinophils were induced by the chemotactic agent, platelet factor 4 (PF4). Taken together, we could conclude that chemotactic agents might be involved in the high intensity expressions of adhesion molecules on eosinophils from BA patients. Moreover, to investigate the mechanisms of the induction of adhesion molecules on EoL-3 cells by PF4, sICAM-1 levels in the supernatants of EoL-3 with PF4 and without PF4 were examined. In our results, the presence or absence of PF4 made no difference in sICAM-1 levels, suggesting that the shedding of ICAM-1 has little relation to the induction of adhesion molecules.

Balloon angioplasty for postoperative pulmonary artery stenosis in transposition of the great arteries

OBJECTIVES

This study was designed to assess the success rate and determinants of success or failure of balloon angioplasty for postoperative pulmonary stenosis in patients with transposition of the great arteries.

BACKGROUND

Previous reports have suggested that pulmonary stenosis that develops after the arterial switch operation is not likely to be dilated.

METHODS

Twenty-eight patients with transposition of the great arteries underwent 39 balloon angioplasty procedures after the arterial switch operation. The mean age at dilation was 4.5 +/- 2.2 years (range 0.7 to 9.8), and the interval between operation and balloon dilation was 3.6 +/- 1.8 years. The criterion of successful dilation was a > or = 50% increase in predilation diameter or a > or = 50% decrease in predilation pressure gradient. If the right ventricular/aortic pressure ratio decreased by > or = 0.2, so that the ratio became < 0.68, reoperation was thought to be not indicated.

RESULTS

The success rate of balloon angioplasty for pulmonary artery stenosis was 51% (20 of 39 dilations). The mean age at dilation in the group with successful dilation (3.6 years) was significantly younger than that in the group with unsuccessful dilation (5.4 years). The interval between operation and dilation in the successful dilation group (2.4 years) was significantly less than that in the unsuccessful dilation group (4.6 years). In 13 patients who underwent balloon angioplasty < 3.5 years after operation, balloon dilation was successful in 92%. The balloon/artery ratio was significantly greater in the successful than in the unsuccessful dilation group. A right ventricular/aortic pressure ratio > or = 0.68 was observed in 20 patients, and reoperation was not indicated in 10 patients (50%). There was no death, but one pulmonary artery rupture that did not require surgical intervention occurred. Aneurysmal dilation of the pulmonary artery was observed in three patients.

CONCLUSIONS

These data indicate that although the success rate of balloon angioplasty for pulmonary artery stenosis after the arterial switch operation is low (approximately 50%), balloon angioplasty can be the first therapeutic choice owing to the low complication rate and the potential benefit of the procedure. The success rate can be high if angioplasty is performed < 3.5 years after operation and a balloon of adequate size is used.

[The measurement of eosinophil granule proteins]

It has been known that eosinophilia in the peripheral blood or tissue participate in allergic inflammatory reactions and parasitic diseases. The function of eosinophils depend on the biological activity of the granule proteins. Four of these protein-MBP, ECP, EPO, and EDN have been known. There are some assumptions that the eosinophils might cause a tissue damage on examination of their specific protein. Therefore, the measurements of these granule proteins might clarify the pathogenesis of eosinophils related diseases. In this review, we introduce a convenient method for purification, quantitative measurement in serum, BAL and detection of localization in tissue by an immunofluorescence method for specific staining of eosinophil granule proteins.

Combined assessment with myocardial contractility and an index related to ventricular afterload in patients with isolated severe mitral regurgitation undergoing valve replacement. A retrospective study

The afterload to the left ventricle increases following valve replacement in chronic mitral regurgitation (MR), yet there has been no study taking into account left ventricular (LV) afterload. In 43 patients with isolated chronic MR undergoing mitral valve replacement (MVR), we calculated LV wall stress using preoperative LV end-diastolic dimensions and diastolic aortic pressure (predictive LV wall stress = pWS). This value would represent LV wall stress at the instant of aortic valve opening immediately after MVR, assuming that LV end-diastolic dimensions and the aortic pressure did not change after operation. We also calculated end-systolic wall stress/volume index (ESS/ESVI) ratio, an index of myocardial function. None of 15 patients with the ESS/ESVI ratio > 1.6 had postoperative mortality or morbidity, whereas among the 26 patients with the ESS/ESVI ratio < 1.6, 12 patients had mortality (3 patients) and/or morbidity requiring intraaortic balloon pumping or prolonged catecholamine support. Three patients who died had pWS > 200 kdynes/cm2. Including these 3, all 5 patients whose pWS > 200 had mortality or severe morbidity immediately after surgery. In contrast, among the 38 patients with lower pWS, none died and only 7 patients (18%) had morbidity. Thus, patients who had a low contractility index and a high predictive afterload value had high mortality and morbidity. We conclude that the prediction of postoperative mortality and morbidity is improved by combined assessment of myocardial function and the hypothetical postoperative LV afterload.

HCO3(-)-dependent intracellular pH regulation in the premature myocardium

This study investigated developmental changes in Na(+)-H+ exchange and HCO3(-)-Cl- exchange activities in newborn and adult rabbit hearts. pHi was measured using the fluorescent dye 2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein in isolated myocytes. Myocardial mechanical function was measured in the isolated ventricular preparation. Intracellular acidosis with normal pHo was induced by an NH4Cl (10 mM) prepulse technique. Upon removal of NH4Cl, pHi fell transiently and then recovered toward the control level. In the HCO3-/CO2-buffered solution, the rate of recovery of pHi in the newborn was greater than in the adult. In the HCO3-/CO2-buffered solution, 5-(N-ethyl-N-isopropyl)amiloride (EIPA), an inhibitor of Na(+)-H+ exchange, inhibited the recovery of pHi completely in the adult. In the newborn, however, significant recovery of pHi was observed in the presence of EIPA. In the presence of both EIPA and 4-acetamido-4'-isothiocyanatostilbene-2',2'-disulfonic acid (SITS), an inhibitor of HCO3(-)-Cl- exchange, the recovery of pHi was not observed in the two age groups. In the HEPES-buffered solution that did not contain HCO3-/CO2, the rate of recovery of pHi after NH4Cl removal was similar in the two age groups. In the HEPES-buffered solution, the recovery of pHi was completely inhibited by EIPA in the two age groups. In the presence of EIPA in the HCO3-/CO2-buffered solution, contractile function decreased during acidosis after NH4Cl removal and did not recover in the adult. In the newborn, significant recovery of contractile function was observed after NH4Cl removal in the presence of EIPA. The recovery of mechanical function observed in the presence of EIPA in the newborn was inhibited by SITS. These data suggest that, although there is no developmental change in the Na(+)-H+ exchange activity, HCO3(-)-Cl- exchange is more active in the premature myocardium. The presence of the HCO3(-)-Cl- exchanger is important in maintaining myocardial contractile function during acidosis, especially when Na(+)-H+ exchange is inhibited and may partly explain the greater resistance of the premature myocardium to acidosis.

Possible induction of intercellular adhesion molecule-1 (ICAM-1) expression on endothelial cells by platelet-activating factor (PAF)

We demonstrated that PAF and IL-1 markedly induce ICAM-1 expression on endothelial cells. These findings suggest that PAF not only modulates inflammation by the attraction and activation of eosinophils or by platelet activation, but also intensifies such phenomena by induction of ICAM-1 expression on endothelial cells.

A case report of familial cyclic neutropenia

A 34-year-old female with cyclic neutropenia is reported. Family studies showed that her three sons and her mother were also involved. Oscillations in the blood neutrophil counts were almost regular, with a periodicity of 21 days. Numbers of colony-forming unit--granulocyte macrophage (CFU-GM) formed from the bone marrow cells of normal volunteers co-cultured with the patient's serum or mononuclear cell-conditioned medium (MNC-CM) were examined. Her serum prepared during the neutropenic phase inhibited the growth of CFU-GM, while her MNC-CM stimulated it. Human granulocyte colony-stimulating factor (hG-CSF) level in her serum was persistently high, with the peak occurring during the neutropenic phase. These results suggest that some inhibitory factors in the serum may be pathophysiologically important for cyclic neutropenia. To control infections, a pharmacological dose of hG-CSF was administered for 7 days around the early neutropenic phase. Her peripheral neutrophil counts oscillated from 1,200/mm3 to 17,000/mm3 with G-CSF, and from 150/mm3 to 1,800/mm3 without G-CSF.

[Caudal-angle aortography. Its usefulness for defining the coronary anatomy in cases of transposition of the great vessels]

With the purpose of obtaining an accurate definition of coronary arteries anatomy in complete transposition of the great arteries (concordant atrio-ventricular connection and discordant ventriculo-arterial connection), we performed a new angiographic technique in 14 patients with d-transposition of the great arteries and 1 patient with double-outlet right ventricle. This technique consists of using a balloon catheter with the frontal X ray tube cine-angiographic camera in caudal angulation (about 45 degrees), with balloon occlusion of the ascending aorta during the injection of the contrast medium. The results were compared with echocardiograms and surgical results. In all our cases, except 2, the technique gave us a very clear definition of the coronary anatomy and we were able to define the origin and course of the coronary arteries without difficulty. In the most common coronary artery pattern, the left coronary artery arose from sinus #1 (left aortic sinus) and gave origin to the anterior descending and left circumflex arteries, while the right coronary artery arose from aortic sinus #2 (right aortic sinus). In our series, the coronary arteries always originated from one or both facing sinuses of the aorta and the angiographic correlation with the surgical reports was accurate in all the cases. The anatomical and angiographic findings of this series are discussed. In conclusion, we find the aortogram with caudal angulation a very useful technique to improve the visualization of coronary anatomy in d-transposition of the great arteries, which has surgical significance in those cases which are candidates for anatomical correction.

Effect of partial Na pump and Na-H exchange inhibition on [Ca]i during acidosis in cardiac cells

This study investigated the effects of partial Na pump inhibition and Na-H exchange inhibition on contractile function, intracellular pH (pHi), and intracellular Ca concentration ([Ca]i) during intracellular acidosis, using the fluorescent dyes 2',7'-bis(carboxyethyl)-5,6-carboxyfluorescein and fura-2 in isolated cardiac cells of adult rabbits. Intracellular acidosis with normal extracellular pH was induced by an NH4Cl (10 mM) prepulse technique. A nontoxic concentration (0.5 microM) of ouabain was used to inhibit the Na pump. 5-(N-ethyl-N-isopropyl)amiloride (EIPA) was used to inhibit Na-H exchange. In both the absence and presence of ouabain, pHi fell transiently and then recovered after removal of NH4Cl. Ouabain did not alter the pHi changes observed after removal of NH4Cl. Diastolic and systolic [Ca]i increased during acidosis after NH4Cl removal. In the presence of ouabain, the increase in [Ca]i during acidosis was greater than that in the absence of this drug. Ouabain enhanced the recovery of contractile function during acidosis. In both the absence and presence of ouabain, Na-H exchange inhibition by EIPA reduced the recovery of pHi and mechanical function and the increase in [Ca]i, which were normally observed after NH4Cl removal. These data suggest that in adult rabbit myocytes the Na pump inhibition enhances the increase in [Ca]i during acidosis, and the Na-H exchange inhibition reduces it. The [Ca]i increase during acidosis may be in part due to the altered Na-Ca exchange, which in turn results from the increased Na-H exchange.

Ostial stenosis of the left coronary artery as a sole clinical manifestation of Takayasu's arteritis: a possible cause of unexpected sudden death

An 11-year-old girl experienced several syncopal attacks and her electrocardiogram showed ST depression with exercise. Ostial stenosis of the left coronary artery was disclosed by the coronary angiography. We suspected the coronary involvement was due to Takayasu's arteritis. On operation, aortitis in the ascending aorta involving ostium of the left coronary artery was observed. Therefore Takayasu's arteritis is considered to be one of the causes of sudden death.

Effect of acidosis on intracellular pH and calcium concentration in the newborn and adult rabbit myocardium

This study investigated developmental changes in the effect of acidosis on intracellular pH (pHi) and [Ca]i in the isolated heart and isolated myocyte preparations. The whole heart or myocytes of newborn (5-7 days old) and adult rabbits were loaded with the fluorescent pH indicator 2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein (BCECF) or calcium indicator fura-2. Left ventricular pressure in the isolated heart preparation and the magnitude of cell contraction in the single-cell preparation were monitored. The heart and single cell were illuminated with excitation lights (340 and 380 nm, respectively, for fura-2 and 438 and 490 nm for BCECF). The intensity of fluorescence from the ventricular surface or from the cell was detected. [Ca]i was estimated from the following ratio: fluorescence at 505 nm during excitation at 340 nm/fluorescence at 505 nm during excitation at 380 nm. pHi was estimated from the following ratio: fluorescence at 530 nm during excitation at 490 nm/fluorescence at 530 nm during excitation at 438 nm. In the newborn, depression of contractile function during respiratory acidosis or metabolic acidosis was less than in the adult. Diastolic and systolic [Ca]i increased during respiratory acidosis in both the newborn and adult, and the net changes in [Ca]i were similar in the two age groups. During respiratory or metabolic acidosis, pHi decreased, but the decrease in the newborn was significantly less than in the adult. These data suggest that the greater resistance of the newborn myocardium to acidosis is due to the smaller change of pHi in this age group and not due to the difference in [Ca]i alteration.

Myocardial perfusion after aortic implantation for anomalous origin of the left coronary artery from the pulmonary artery

Postoperative myocardial perfusion and function were evaluated using thallium-201 myocardial imaging and technetium-99m cardiac pool imaging in five patients with an anomalous left coronary artery arising from the pulmonary artery. The patients underwent reimplantation of the left coronary artery at an age ranging from 10 months to 13 years. Postoperative electrocardiographic and radionuclide studies were performed both at rest and during stress 1 to 4 years after the operation. Electrocardiograms which were abnormal preoperatively returned to normal after surgery except that the T wave in lead aVL remained negative. Postoperatively, left ventricular ejection fraction measured by technetium-99m cardiac pool imaging was normal in all patients. Postoperative thallium-201 myocardial imaging, however, showed a perfusion defect with incomplete redistribution at the high-lateral or antero-lateral segment in all patients after a stress test. These data suggest that although myocardial ischaemic change decreases and global cardiac function improves after establishment of a dual coronary artery system, severe myocardial damage remains at the high-lateral or antero-lateral segment.

Inotropic effect of phenylephrine and myocardial alpha-adrenergic receptor in newborn and adult animals

Developmental changes in the myocardial alpha-receptor density were studied using rabbit, rat and dog hearts. In all species studied, alpha-receptor density in the newborn was greater than in the adult. The inotropic effect of phenylephrine was measured using the isolated arterially perfused heart preparation of rabbit and rat. The heart was stimulated electrically at 40/min. In the presence of propranolol, phenylephrine caused a significant positive inotropic effect which was significantly less in the newborn than in the adult. Since alpha-adrenergic stimulation activates protein kinase C, the inotropic effect of protein kinase C activation was studied in the rabbit and rat using phorbol myristate acetate (PMA). PMA caused a negative inotropic effect and the decrease in contractile function in the newborn was greater than in the adult. These data suggest that myocardial alpha-receptor density decreases and the positive inotropic effect of alpha-agonist increases with development. The reasons for this discrepancy remain unclear but there may be developmental differences in the signal transduction processes of alpha-stimulation. The greater negative inotropy of protein kinase C activation in the premature heart may be one of the mechanisms of the reduced inotropy of alpha-agonist in this age group.