A case of an elderly man who required repeated repair of a ventricular septal defect and tricuspid rupture after blunt chest trauma.

Several cases of traumatic ventricular septal defect (VSD) have been reported. However, traumatic VSD complicated by tricuspid rupture is rare. We report a case of traumatic VSD with tricuspid rupture who required repeated repair of both conditions. A 69-year-old man was transferred to our hospital for emergent surgical repair of traumatic VSD and tricuspid rupture. Although emergent repair was performed, a new left-to-right shunt and moderate tricuspid regurgitation appeared during his postoperative course. A reoperation was performed 4 months after the first operation. The borders of the defect were very fibrotic and strong compared with those in the first operation. Surgical treatment of traumatic VSD should be postponed in hemodynamically stable patients. When emergent repair is performed, careful follow-up is necessary to diagnose new VSD.

Gastric injury caused by low-dose aspirin therapy in consecutive Japanese patients: a prospective study.

PURPOSE: Low-dose aspirin (<325 mg/day), administered to those with several conditions involving ischemic disorders, can cause upper gastrointestinal (GI) complications. In this prospective study, we aimed to clarify the incidence of aspirin-induced gastric ulcers in consecutive Japanese patients and identify suitable preventive measures. METHODS: We recruited 125 consecutive adult outpatients who received low-dose aspirin (enteric-coated tablets 100 mg) for >8 weeks. Endoscopy and blood tests were used to evaluate their gastric injury (which was scored using a modified Lanza scale) and anti-Helicobacter pylori antibody titer, respectively. RESULTS: We found that 39.8% of patients received either no upper GI drug or only mucoprotective drugs, 39.8% received medium-dose histamine H2 blockers, and 20.4% received proton-pump inhibitors (PPIs). Anti-H. pylori antibody titers were positive in 43.7% of patients. The incidence of definitive gastric ulcers in this population was 0.97%. Ordered logistic regression analysis revealed that the odds ratio for the increase in the modified Lanza score was 0.20 for medium-dose histamine H2 blockers and 0.09 for PPIs. CONCLUSION: The incidence of postoperative definitive gastric ulcers in Japanese patients receiving ≤100 mg enteric-coated aspirin was 0.97%. The use of PPIs and histamine H(2) blockers may prevent aspirin-induced gastric injury in such patients.

Coronary artery bypass surgery versus percutaneous coronary artery intervention in patients on chronic hemodialysis: does a drug-eluting stent have an impact on clinical outcome?

Coronary revascularization methods continue to be refined, and the emergence of the drug-eluting stent (DES) has especially changed clinical practice related to ischemic heart disease. For chronic hemodialysis (HD) patients, however, the impact of DES on clinical outcome is yet to be determined. Forty-six consecutive chronic HD patients who underwent myocardial revascularization in our institute were retrospectively reviewed. Twenty-eight patients underwent coronary artery bypass surgery (CABG) and 18 patients underwent percutaneous coronary artery intervention (PCI). Patient characteristics were similar between the two groups. In the CABG group, bilateral internal thoracic artery (ITA) bypass grafting was performed in 27 patients and off-pump CABG was performed in 20 patients. In the PCI group, a DES was used in 12 patients. The number of coronary vessels treated per patient was higher in the CABG group (CABG: 4.25 +/- 1.32 vs. PCI: 1.44 +/- 0.78; p < 0.001). Two-year survival rates were similar between the two groups (CABG: 94.1% vs. PCI: 73.9%; p = 0.41), but major adverse cardiac event-free survival (CABG: 85.9% vs. PCI: 37.1%; p = 0.001) and angina-free survival (CABG: 84.9% vs. PCI: 28.9%; p < 0.001) rates were significantly higher in the CABG group. The one-year patency rate for the CABG grafts was 93.3% (left ITA: 100%, right ITA: 84.6%, sapenous vein: 90.9%, gastro-epiploic artery: 100%), and six-month restenosis rate for PCI was 57.1% (balloon angio-plasty: 75%, bare metal stent 40%, DES: 58.3%). Even in the era of DES, clinical results favored CABG. The difference in clinical results is due to the sustainability of successful revascularization.

Clinical features and characteristics of blood flow of uterine vascular abnormalities.

PURPOSE: The purpose of this study was to assess the clinical features and characteristics of the blood flow in uterine vascular abnormalities using ultrasound and magnetic resonance imaging (MRI). METHODS: A total of 17 women were diagnosed with uterine vascular abnormalities by ultrasound. The clinical characteristics of the patients and the distribution and waveform of the intrauterine vessels were examined using transvaginal gray-scale and Doppler ultrasonography, spin-echo MRI, and MR angiography. RESULTS: The average age of the 17 subjects was 44.3 years, and 5 were postmenopausal women. The number of pregnancies and deliveries was 2.0 and 1.7, respectively. Of the 17 subjects, 7 had a moderate or severe grade of dysmenorrhea and 7 had a history of vascular disease. In all subjects, vaginal ultrasound demonstrated tubular or numerous tortuous anechoic areas in the uterine wall, and Doppler ultrasound showed that the tubular or numerous dilated tortuous vessels had an atypical wave flow, unlike that of an artery or a vein. The distribution of displayed flow varied, and the waveforms of the Doppler ultrasound displayed three patterns. The averages of the pulse Doppler flow indices showed low impedance in the abnormal uterine vessel and the uterine artery, especially in cases of true arteriovenous malformations. MR angiography demonstrated distinct, tortuous, and coiled vascular channels in the pelvis during and just after the arterial phase. CONCLUSION: Characterization of the clinical features of uterine vascular abnormalities is considered to be valuable for obstetricians and gynecologists.

Influence of carotid artery stenosis on stroke in patients undergoing off-pump coronary artery bypass grafting.

OBJECTIVE: It is well known that the presence of carotid artery stenosis increases the risk of perioperative stroke in patients undergoing cardiac surgery with cardiopulmonary bypass. Although off-pump coronary artery bypass grafting (CABG) can avoid the adverse effects of cardiopulmonary bypass, the influence of carotid artery stenosis on the incidence of stroke in patients undergoing off-pump CABG has not been well clarified. METHODS: We conducted a retrospective study of 461 patients who underwent elective off-pump CABG after screening for carotid artery stenosis at our institute between September 2004 and May 2007. The incidence and etiologies of stroke were identified. Preoperative screening revealed significant carotid artery stenosis in 49 patients. Clinical results were compared between patients with and without carotid artery stenosis. RESULTS: Postoperative stroke occurred in two (0.43%) of the 462 study patients, and in-hospital mortality occurred in three (0.65%). Stroke was due to decreased perfusion resulting from hypovolemic shock in one and thrombosis in the other. There was neither stroke nor in-hospital mortality in patients with carotid artery stenosis, although there were two strokes (0.49%) and three in-hospital mortalities (0.73%) in patients without carotid artery stenosis. CONCLUSIONS: The influence of carotid artery stenosis on the incidence of perioperative stroke may be little in off-pump CABG, especially in patients with moderate carotid artery stenosis.

Outcome of surgical treatment in patients with acute type B aortic dissection.

BACKGROUND: Surgery for acute type B aortic dissection is associated with significant mortality and morbidity. The purpose of this study was to assess the clinical outcome of surgical management of complicated acute type B aortic dissection. METHODS: During the last 5 years, 112 patients were admitted for acute type B aortic dissection. Of these patients, 24 consecutive patients were enrolled who underwent surgical management during the acute or subacute stage. The mean age was 66.7 +/- 9.1 years; 8 patients were female. Indications for surgery were rupture in 10 patients, impending rupture in 7, and malperfusion in 7. Fifteen patients were transferred from another hospital. The overall clinical outcome including morbidity, aorta-related events, and death were retrospectively assessed. RESULTS: The mean duration from the time of onset to surgery was 7.1 +/- 9.0 days. Graft replacement of the aorta included the total aortic arch with cerebral perfusion in 6 patients, and replacement of the distal aortic arch or descending aorta with left heart bypass in 12. The remaining 6 patients underwent peripheral bypass for ischemia. Significant complications occurred in 7 patients (24.8%). The operative mortality rate was 8.3% (2 of 24); 5.6% (1 of 18) with central operation and 16.7% (1 of 6) with peripheral operation. The 5-year survival rate was 82.6 +/- 7.9% and freedom from aorta-related events at 1 and 5 years were 95.2% +/- 4.7% and 68.0% +/- 16.6%, respectively. CONCLUSIONS: Surgical management of patients with complicated acute type B dissection has an acceptable perioperative risk and survival. This study suggests earlier surgery with left heart bypass may be beneficial for appropriate patients.

Long-term echocardiography results of mitral valve repair for mitral valve prolapse.

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess the long-term durability of mitral valve (MV) repair for MV prolapse using echo-Doppler evaluation. METHODS: Between July 1991 and December 2006, MV repair was performed in 603 patients with nonischemic, severe mitral regurgitation (MR). A subset of 517 patients (mean age 56.3 +/- 12.0 years) with MR caused by leaflet prolapse resulting from degeneration of the MV was subsequently investigated. The main techniques used for MV repair included chordal replacement with ePTFE sutures for 274 of 278 patients with anterior leaflet (AL) prolapse, and leaflet resection for 239 patients with posterior leaflet (PL) prolapse. A prosthetic ring or band was used for annuloplasty in 340 patients, and a band of autologous pericardium in 161; no ring or band was used in the remaining 16 cases. Postoperative serial transthoracic echocardiography was performed for all hospital survivors before discharge, and on at least one occasion after discharge in 507 patients. Echocardiographic follow up was available for up to 15 years (mean 4.4 +/- 3.6 years). Residual MR flow detected by color Doppler echocardiography was classified according to the maximum regurgitant jet area (MRA). RESULTS: The 30-day mortality was 0.57% (three deaths). There were 21 late deaths and 22 reoperations (five of which were re-repair for hemolysis). Kaplan-Meier survival and freedom from reoperation at 14 years were 79.0 +/- 6.0% and 74.5 +/- 9.6%, respectively. Estimates of freedom from severe MR (MRA > or = 7.0 cm2) at five, 10 and 14 years were 94.2 +/- 1.5%, 82.8 +/- 3.6% and 77.5 +/- 5.5%, respectively. Freedom from severe MR at 14 years for 239 patients with isolated PL prolapse was 98.4 +/- 1.6%. CONCLUSION: Echocardiographic follow up of MV repair for MV prolapse demonstrates good long-term results. In particular, the results of MV repair for isolated PL prolapse were excellent.

Management of intraoperative malperfusion syndrome using femoral artery cannulation for repair of acute type A aortic dissection.

BACKGROUND: The site of cannulation for repair of ascending aortic dissection remains controversial. The objective of this study was to evaluate the incidence and management of intraoperative malperfusion syndrome using femoral cannulation for repair of acute type A aortic dissection. METHODS: Between May 2002 and February 2007, 107 patients with initial femoral artery cannulation for the repair of type A aortic dissection were enrolled in this study. The mean age was 63.7 +/- 11.8 years; 51 patients were female. Preoperative findings indicated malperfusion in 16 patients. Intraoperative malperfusion syndrome was diagnosed by both radial arterial pressure measurements and transesophageal echocardiography. Clinical outcomes, including specific operative procedures and complications related to the cannulation, were assessed. RESULTS: The ascending aorta was replaced in 59 patients, hemiarch in 16, and total aortic arch in 32. Intraoperative malperfusion syndrome was noted in 3 patients (lowering of radial pressure in 2, obstruction of the true lumen in 1) at the initiation of cardiopulmonary bypass. After immediately switching to transventricular cannulation, the surgical replacement was successfully performed. The remaining 104 patients underwent surgery during femoral artery bypass without perfusion abnormalities. There was 1 in-hospital death (0.9%), but no deaths among the malperfusion patients. Cerebrovascular deficit occurred in 7 patients (6.5%). One vascular and 3 wound complications occurred related to the femoral cannulation. CONCLUSIONS: During the repair of acute ascending aortic dissection, malperfusion syndrome related to femoral artery cannulation has an acceptable incidence, and can be managed under appropriate intraoperative monitoring, particularly at the initiation of cardiopulmonary bypass.

Intermediate-term results of surgical treatment of acute intramural hematoma involving the ascending aorta.

BACKGROUND: The treatment strategy of acute intramural hematoma involving the ascending aorta remains uncertain. The objective of this study was to evaluate the effectiveness of surgical treatment for this condition. METHODS: A total of 41 patients underwent operation for acute intramural hematoma involving the ascending aorta between 2000 and 2006. Mean age was 67.2 +/- 10.1 years, with 26 female patients and 10 in cardiogenic shock at presentation. Early and midterm results, including mortality, morbidity, survival, event-free rates, and the persistence of residual hematoma, were analyzed retrospectively in all patients. Mean follow-up period was 29.7 +/- 18.1 months. RESULTS: All but one patient underwent operation within 72 hours from the onset of symptoms. Thirty-four patients underwent isolated ascending aortic replacement, three had hemiarch repair, and four required total arch replacement. There were no in-hospital deaths. Stroke occurred in two patients and transient neurologic dysfunction in one. Postoperative computed tomographic scan showed residual distal hematoma progression to classical double-barrel dissection in two patients. At five years follow-up, survival was 100%. During the follow-up period, one patient had a new type B aortic dissection. A follow-up study confirmed hematoma resorption in 29 patients (70.7%). The estimated freedom from intramural hematoma-related events was 92.6 +/- 4.1% at five years. No independent predictor of intramural hematoma-related events was found on multivariate analysis. CONCLUSIONS: Immediate surgical treatment of acute aortic intramural hematoma involving the ascending aorta with open distal replacement of ascending aorta results in lower mortality rates and excellent midterm survival.

Purification, cloning, and sequence analysis of beta-N-acetylglucosaminidase from the chitinolytic bacterium Aeromonas hydrophila strain SUWA-9.

A chitinolytic bacterium was isolated from Lake Suwa and identified as Aeromonas hydrophila strain SUWA-9. The strain grew well on a synthetic medium containing colloidal chitin as sole carbon source. Chitin-degrading activity was induced by colloidal chitin or N-acetylglucosamine (GlcNAc). Most of the activity, however, was not detected in culture fluid but was associated with cells. A beta-N-acetylglucosaminidase was purified after it was solubilized from cells by sonication. The purified enzyme hydrolyzed N-acetylchitooligomers from dimer to pentamer and produced GlcNAc as a final product. The enzyme also hydrolyzed synthetic substrates such as p-nitrophenyl (pNP)-N-acetyl-beta-D-glucosaminide and pNP-N-acetyl-beta-D-galactosaminide. A gene coding for the purified beta-N-acetylglucosaminidase was isolated. The ORF identified is 2661 nucleotides long and encodes a precursor protein of 887 amino acids including a signal peptide of 22 amino acid residues. The amino acid sequence deduced showed a high similarity to those of bacterial beta-N-acetylhexosaminidases classified in family 20 of glycosyl hydrolases.