Aortic valve replacement in small patients.

OBJECTIVES: Asians are smaller than Europeans and North Americans, but aortic valve replacement (AVR) in small patients has not been examined. We aimed to compare short- and mid-term outcomes of AVR between small and non-small patients. METHODS: We retrospectively divided 173 patients who underwent AVR into small (S, n = 95) and non-small (NS, n = 78) groups according to body surface area (≤1.6 in men, ≤1.5 in women) and analyzed differences in baseline characteristics, procedural and post-procedural variables, and survival. RESULTS: Mean age differed significantly between the S and NS groups (71.9 ± 11.2 vs. 66.2 ± 9.8 years), as did the proportion of women (60.0% vs. 24.4%). Implanted valves (19.6 ± 1.6 mm vs. 20.7 ± 1.7 mm) were significantly smaller and more bioprosthetic valves (57.9% vs. 41.0%) were used in the S group. Effective orifice area index and the rate of moderate and severe patient-prosthesis mismatch were not significantly different. No significant intergroup differences were found in hospitalization duration, 30-day mortality, survival rates, or valve related complications. CONCLUSIONS: Small patients were older and the proportion of women was higher. The implanted aortic valves were smaller and more were biological prostheses. However, mortality rate did not differ and short- and mid-term outcomes were safe and favorable.

Surgery for primary cardiac tumors. Clinical experience and surgical results in 60 patients.

BACKGROUND: We reviewed our clinical experience with primary cardiac tumors, attempting to clarify the surgical management of these rare entities. METHODS: Between October 1978 and November 1999, we experienced 60 surgical cases of primary cardiac tumors. There were 23 male and 37 female patients (age range, 7 months to 84 years). Tumors included the following 3 groups: myxomas (n=49), nonmyxoma benign tumors (n=3), and malignant tumors (n=8). We reviewed the presenting symptoms, diagnostic data, anatomical findings, and surgical techniques, and evaluated the surgical RESULTS. Late follow-up was 95% complete (mean follow-up, 7.7+/-7.1 years). RESULTS: Tumors produced obstructive, embolic, and/or constitutional symptoms in most cases. Generally, echocardiography alone gave sufficient information for operation. Full-thickness excision was performed in 42 patients with myxoma. Complete excision was achieved in all of the nonmyxoma benign tumors and in none of the malignancies. Early mortalities in the 3 groups were 8.2% (4/49), 0% (0/3), and 12.5% (1/8), respectively. Late mortalities were 9.5% (4/42), 0% (0/3), and 100% (7/7), respectively. One patient with myxoma had recurrence, the cause of which was likely to be inadequate resection. The late deaths in patients with malignancies were due to metastasis or local recurrence. CONCLUSIONS: Benign tumors are generally curable if surgically excised. Preoperative refractory cardiac dysfunction or embolism should be avoided by the accurate evaluation on echocardiography. The prognosis of malignant tumors is poor if they are only debulked. However, aggressive surgery that can palliate obstruction and allow time for adjuvant therapy should be carried out.

Pulmonary artery aneurysms developed in a family.

Pulmonary artery aneurysm (PAA) is a rare condition, and its pathogenesis and clinical significance are not clearly understood. Although reports of this condition have increased, PAAs developed in a family have never been reported. We describe PAA associated with atrial septal defect in a mother and daughter. A PAA in the mother was treated by pulmonary root replacement with a Freestyle aortic root bioprosthesis. A PAA in the daughter has been followed up because of a small shunt through the defect. In addition to the increased pulmonary blood flow, congenital weakness of the PA wall must have contributed to development of PAAs in our patients.

Immobilization of bisphosphonates on surface modified titanium.

The efficiency of surface modifications on the immobilization of bisphosphonates on titanium was investigated with Ca-ion implantation and thin hydroxyapatite coatings. The ALP activity of osteoblastic cells and the inhibitory effects on the initial adherence of P. gingivalis were also evaluated using bisphosphonate-immobilized titanium. X-ray photoelectron spectroscopy analysis suggested that titanium surfaces modified with Ca-ion implantation and thin hydroxyapatite coatings caused the immobilization of bisphosphonate on titanium plates. The ALP activity of osteoblastic cells cultured on plates immobilized with bisphosphonate was almost the same as that of cells cultured on titanium plates, indicating that the bisphosphonate-immobilization showed no toxic effect on osteoblastic cells, and that it provides a favorable micro-environment with osteogenetic ability. Data of the adherence of oral bacteria showed that a bisphosphonate-immobilized titanium surface inhibited the initial adherence of P. gingivalis. These results indicate that the immobilization of bisphosphonates on titanium modified with Ca-ion implantation and thin hydroxyapatite coatings are useful for dental implants.

Coronary artery bypass grafting in patients with mild renal insufficiency.

UNLABELLED: It is well known that dialysis-dependent renal failure increases the likelihood of a poor outcome following cardiac surgery. However, it is not known whether non-dialysis-dependent mild renal insufficiency also influences clinical outcome. Fifty-five patients with non-dialysis-dependent renal insufficiency undergoing coronary artery bypass grafting (CABG) (Renal group: serum creatinine level >1.5 mg/dl) were enrolled. These patients were then matched on prognostic variables to 148 patients with normal renal function ( CONTROL GROUP: serum creatinine level <1.5 mg/dl). The early postoperative clinical results showed that patients in the Renal group were more likely to develop postoperative renal failure (18% vs 1%: p=0.0002) and hemorrhage requiring re-exploration (11% vs 2%; p=0.01). Total morbidity was significantly higher in the Renal group (40% vs 22%; p=0.01). Multivariate analysis revealed that the Renal group was the second most important predictor of morbidity (odds ratio (OR) =2.2) behind left ventricular dysfunction (OR=2.9). The Renal group was also the second most important predictor of postoperative renal failure (OR=12.5). Therefore, non-dialysis-dependent mild renal insufficiency also increases the risk of morbidity following CABG.

Biological activity of endogenous atrial natriuretic peptide during cardiopulmonary bypass.

To evaluate the effect of cardiopulmonary bypass (CPB) on atrial natriuretic peptide (ANP) biological activity in patients undergoing cardiac operations, we conducted a prospective study. Ten patients undergoing mitral valve surgery were enrolled. Plasma levels of ANP and cyclic guanosine monophosphate (cGMP), hemodynamic variables, and renal function parameters were assessed perioperatively. The molar ratio of cGMP to ANP (as a marker for ANP biological activity) decreased significantly (p < 0.05) during CPB despite similar plasma ANP levels. The ratio correlated inversely with the duration of CPB (r = -0.85, p = 0.002). The ratio also correlated with fractional sodium excretion (r = 0.65, p = 0.04) and correlated inversely with pulmonary vascular resistance (r = -0.79, p = 0.009) and atrial filling pressure (r = -0.84, p= 0.003) postoperatively. CPB decreased the molar ratio of cGMP to ANP, which may represent ANP biological activity, such as vasodilation and natriuresis. The phenomenon may contribute to water-sodium retention and pulmonary hypertension after cardiac surgery.

Effects of intraoperative administration of atrial natriuretic peptide.

BACKGROUND: Biological activity of endogenous atrial natriuretic peptide (ANP) may decrease during cardiopulmonary bypass. To evaluate the effects of intraoperative administration of exogenous ANP in patients undergoing cardiopulmonary bypass, we conducted a prospective randomized study. METHODS: Eighteen patients undergoing mitral valve surgery were randomized to receive either ANP treatment (ANP group; n = 9) or no ANP treatment (control group; n = 9). Atrial natriuretic peptide was given immediately after initiation of cardiopulmonary bypass for 6 hours (0.05 microg x kg(-1) x min(-1)). Plasma ANP, brain natriuretic peptide and cyclic guanosine monophosphate (cGMP) levels, hemodynamic variables and renal function were assessed perioperatively. RESULTS: Administration of ANP increased plasma cyclic guanosine monophosphate levels, urine output and fractional sodium excretion, and decreased preload, afterload and plasma brain natriuretic peptide levels significantly (p < 0.05). Plasma cyclic guanosine monophosphate levels correlated with plasma ANP levels (r = 0.95, p = 0.0001), correlated with fractional sodium excretion (r = 0.53, p = 0.02), and correlated inversely with systemic vascular resistance (r = -0.54, p = 0.02). CONCLUSIONS: Intraoperative administration of ANP had potent effects on natriuresis and systemic vasodilation by elevating cyclic guanosine monophosphate levels. The results suggest that the technique is useful for the management of hemodynamics and water-sodium retention after cardiopulmonary bypass.

Effects of angiotensin-converting enzyme inhibitor during warm blood cardioplegia.

BACKGROUND: Effects of captopril, an angiotensin-converting enzyme inhibitor, during warm blood cardioplegia were assessed in the blood-perfused, isolated rat heart. METHODS: The isolated hearts were arrested for 60 minutes with warm blood cardioplegia given at 20-minute intervals and were reperfused for 60 minutes. The control group (n = 10) received standard cardioplegia and the captopril group (n = 10) received cardioplegia supplemented with captopril (2 mmol/L). Cardiac function, myocardial metabolism, and cardiac release of circulating adhesion molecules were assessed before and after cardioplegic arrest. RESULTS: Left ventricular end-diastolic pressure and -dp/dt were significantly (p<0.05) lower and coronary blood flow was significantly (p<0.05) greater in the captopril group than the control group during reperfusion. The captopril group resulted in significantly (p<0.05) less cardiac release of lactate, thiobarbituric acid reactive substances during reperfusion. Cardiac release of intercellular adhesion molecule-1 was significantly (p<0.05) less in the captopril group at 60 minutes of reperfusion. CONCLUSIONS: The results suggest that supplementation of captopril during warm blood cardioplegia provides superior myocardial protection by suppressing lipid peroxidation and leukocyte-endothelial cell interaction during reperfusion.

Coronary artery bypass surgery in a patient with myasthenia gravis.

A 73-year-old man with myasthenia gravis required quadruple coronary artery bypass grafting due to triple-vessel disease. Anesthetic management was performed with general anesthesia using a reduced dose of muscle relaxant with the aid of a neuromuscular transmission monitor. He was extubated 14 hrs after surgery without difficulty under this monitor. His postoperative course was uneventful. A patient with myasthenia gravis who required coronary artery bypass surgery was successfully performed by the deliberate preoperative evaluation of patient's myasthenic and cardiac status, and by the careful perioperative management.

Surgical treatment for graft stenosis after repair of an interrupted aortic arch: report of two cases.

We report herein two cases of patients who underwent successful reoperation for graft stenosis after repair of an interrupted aortic arch (IAA). The first patient was a 10-year-old girl who suffered from upper limb hypertension 9 years after her initial operation. Cardiac catheterization revealed a pressure gradient of 55 mmHg across the repaired arch. At reoperation, a left subclavian turndown anastomosis was performed, following which the hypertension resolved and a cardiac catheterization done 5 years later demonstrated sufficient growth of the restored arch with no significant gradient. The second patient was a 17-year-old boy who suffered from general fatigue and intermittent hypertension 12 years after his initial operation. Cardiac catheterization revealed a gradient of 60 mmHg across the repaired arch. He underwent an extraanatomic ascending to descending aortic bypass employing an additional 18-mm graft, and a postoperative cardiac catheterization showed no gradient between the ascending and descending aorta. Our experience has shown that IAA should be repaired without prosthetic grafts if possible. Although extraanatomic bypass is useful for reducing the operative risks at reoperation, a large graft should be used to avoid the need for a third operation. For young children expected to outgrow a second graft, performing an endogenous anastomosis, such as a left subclavian turndown anastomosis, should be considered as an alternative.

Plasma exchange for hyperbilirubinemia following implantation of a left ventricle assist system: a case report.

A 49-year-old patient with end-stage dilated cardiomyopathy underwent implantation of a left ventricular assist system (LVAS). Although the systemic circulation seemed to be improved, the serum total bilirubin (Tbili) level increased sharply in the early postoperative period (preoperative Tbili, 5.7 mg/dl; postoperative day 3, 33.6 mg/dl). Plasma exchange (PE) was performed 7 times from postoperative day 4, and the Tbili level decreased to 16.3 mg/dl by postoperative day 11. Thereafter, serum Tbili normalized concomitant with improved circulatory condition. The cause of the hyperbilirubinemia was considered to be temporary right ventricular dysfunction or hepatic sinusoid endothelial dysfunction. The liver function was recoverable, so PE had been effective in this case. Unfortunately, the patient suffered a midbrain infarction and ultimately died. From this experience, PE is recommended if it is judged that liver function can be preserved and circulation is adequate, but its implementation should not be delayed. It is essential that LVAS is implanted before damage occurs to end-organ function and thus prevent hyperbilirubinemia.

[Hemodynamic assessment of the Carpentier-Edwards pericardial valve compared with the St. Jude Medical valve in the aortic position using dobutamine-stress echocardiography].

To assess the hemodynamic performance of the prosthetic valve in the aortic position, we examined dobutamine-stress echocardiography (DSE) to the patients underwent AVR with CEP valve or SJM valve. In 23 mm size, there were no significant differences between CEP group and SJM group in Peak velocity of the aortic jet (PV), peak pressure gradient (PPG) and effective orifice area (EOA). On the other hand, in 21 mm size, PV and PPG of the CEP group were significantly lower than those of the SJM group after DSE. The EOA of the CEP group was significantly larger than that of the SJM group after DSE. Our results suggest that the hemodynamic function of the CEP valve is superior to that of the SJM valve especially in small aortic annuli.

Establishment and characterization of a culture system for enzymatically released rat dental pulp cells.

To establish a cell culture system that reflects the dentin formation in dental pulp tissue, we used dental pulp cells enzymatically isolated from rat incisor teeth. During the 20-day culture period, the cells exhibited various phenotypes of the odontoblast differentiation process, from the immature stage to the terminal mineralization stage. The cells began to form the mineralized nodules from day 10, and the nodules became larger by day 20. Alkaline phosphatase (ALP)-positive cells surrounded the mineralized nodules. The ALP activity in the cell layers was maximal on day 5, and gradually decreased to day 20. The calcium content in the cell layers was very low by day 10, and significantly increased from day 15. Sulfated glycosamino-glycans (GAGs) contained in the cell layers increased by day 15, but the content then decreased by day 20. The dental pulp cells produced a small amount of osteocalcin that was released into the culture medium by day 10, and the amount secreted increased markedly from day 15. The expression of osteocalcin and parathyroid hormone/parathyroid hormone-related peptide (PTH/PTHrP) receptor mRNA was evident as early as day 5, and the expression of each gradually increased with the number of days in culture. Dentin matrix protein (Dmp1) mRNA gene transcripts were identified by use of the reverse transcription polymerase chain reaction (RT-PCR) in the cells throughout the culture period. The present results demonstrate that this culture system is useful for studying the differentiation process of the odontoblast-like cells.

Simultaneous repair of cardiovascular disorders and pectus deformity in a patient with Sprintzen-Goldberg syndrome: A case report.

We report a 12-year-old girl with Sprintzen-Goldberg syndrome (SGS) who was complicated with annuloaortic ectasia with aortic regurgitation, mitral valve prolapse with mitral regurgitation, and a severe pectus excavatum. In this patient, aortic root replacement, mitral valve replacement, and sternal elevation were simultaneously performed, and a version of Ravitch's procedure that was technically modified to support the sternum was used for sternal elevation. This modified sternal elevation technique gave excellent operative exposure, and maintained chest wall stability after the operation.

Immunohistochemical profile of basic fibroblast growth factor and heparan sulphate in adult rat mandibular condylar cartilage.

Basic fibroblast growth factor (bFGF) and heparan sulphate (HS) were detected immunohistochemically in mandibular condylar cartilage, and the findings compared with those on epiphyseal articular cartilage. In the condylar cartilage, both bFGF and HS were localized in chondrocytes throughout the various zones including the fibrous, proliferative, mature-cell and hypertrophic zones: bFGF immunostaining was most significant in the proliferative and mature-cell zones, while intense staining for HS was found mainly in the hypertrophic zone. Immunoreaction for bFGF was detected in the nuclei of chondrocytes, whereas HS staining was observed in the cytoplasm. In articular cartilage, only chondrocytes beneath the superficial zone (intermediate zone) demonstrated both bFGF and HS immunoreactivities. Chondrocytes in the deeper calcifying region of the articular cartilage did not immunoreact for either bFGF or HS. These findings suggest that, in contrast to the epiphyseal articular cartilage, a continuous bFGF-mediated remodelling of cells and matrix takes place in mandibular condylar cartilage during the process of endochondral ossification.

Changes in osteoblast phenotype during differentiation of enzymatically isolated rat calvaria cells.

Osteoblasts enzymatically isolated from newborn rat calvariae show various phenotypes including formation of mineralized bone nodules in culture. We investigated the temporal changes in osteoblast phenotype in these cells up to day 20 in culture. These cells formed unmineralized nodules by day 5. Mineralization was observed at the center of nodules by day 10, and nodules became larger on day 15. The nodules were surrounded by numerous alkaline phosphatase (ALP)-positive cells. ALP activity gradually increased by day 20. Parathyroid hormone (PTH) responsiveness increased with time in culture. Osteoblasts produced no osteocalcin by day 10, but its synthesis was detected from day 15. These cells expressed substantial levels of ALP and PTH/PTHrP receptor mRNAs as early as day 5 in culture, but very weak expression of osteocalcin mRNA on day 5. The levels of expression of these transcripts increased with time in culture. In situ hybridization demonstrated that PTH/PTHrP receptor and osteocalcin mRNAs were strongly expressed in nodules, but the former appeared much earlier than the latter. BMP-2 and BMP-4 mRNAs also appeared in the cells forming nodules. Immunohistochemical analysis demonstrated that cells expressing either BMP-2/4 or their receptors (BMPR-IA, BMPR-IB, and BMPR-II) preferentially appeared in nodules. These observations suggested that BMPs play an important role in the formation of mineralized bone nodules in an autocrine and/or paracrine fashion in these cells. The present study confirmed that osteoblasts enzymatically isolated from newborn rat calvariae are a useful tool for studying the differentiation process of osteoblasts.

Ventricular septal defect of the atrioventricular canal type--report of a surgically treated case.

A 19-month-old male infant with Down syndrome was referred for investigation of heart murmur. An electrocardiogram showed normal axis (+100 degrees) of the QRS complex, incomplete right bundle branch block, and biventricular hypertrophy. Echocardiography revealed a ventricular septal defect (VSD) and a cleft of the anterior mitral leaflet with mild value regurgitation. The anterior mitral leaflet and the septal tricuspid leaflet attached to the same level of the ventricular septum were also delineated, however, no atrial septal defects were detected. Cardiac catheterization demonstrated pulmonary hypertension and a left to right shunt at the right ventricle. During operation, no defects in the atrial septum and no cleft of the septal tricuspid leaflet were found. Cleft of the anterior mitral leaflet, continuity between the mitral anterior leaflet and the tricuspid septal leaflet, and a VSD of the atrioventricular canal type were confirmed. The cleft of the anterior mitral leaflet and the VSD were repaired with the aid of cardiopulmonary bypass. The patient recovered uneventfully.

Ovariectomy causes cell proliferation and matrix synthesis in the growth plate cartilage of the adult rat.

The in vivo effects of ovariectomy in rats have been studied on cell proliferation and matrix synthesis in the growth plate cartilage by assessing immunohistochemically the levels of proliferating cell nuclear antigen and chondroitin sulphate proteoglycan(s). The serum levels of insulin-like growth factor-I and growth hormone were also measured by radioimmunoassay procedures. At 5 weeks after ovariectomy, the serum levels of the growth factor were significantly higher than those in sham-operated rats. In contrast, the level of growth hormone was lower. The nuclear staining of proliferating cell nuclear antigen was generally seen in the zone of proliferative chondrocytes from both groups of rats. Whereas almost all chondrocytes in the proliferative zone of ovariectomized rats expressed proliferating cell nuclear antigen immunoreactivity, fewer did so in that of the sham rats. Quantitative image analysis by ACAS 570 laser cytometry demonstrated that the nuclear antigen-positive sites in ovariectomized rats had significantly higher integrated values (staining intensity), areas and perimeters than those in sham rats. In addition, the number of chondroitin sulphate proteoglycan-immunoreactive cells in the proliferative chondrocytes was also higher in ovariectomized rats than in sham ones. These results suggest that ovariectomy significantly stimulates the cell proliferation and matrix synthesis in the growth plate cartilage, probably through the higher serum level of insulin-like growth factor-I.

The effects of estrogen deficiency on glycosylation of odontoblasts in rats.

To investigate the effects of estrogen deficiency on odontoblast metabolism, we induced osteoporosis in rats by ovariectomy and examined the glycosylation of the matrix component in odontoblasts. Peanut agglutinin (PNA) lectin histochemistry, which detects D-galactose and N-acetylgalactosamine sugars, was conducted in incisor odontoblasts of ovariectomized (OVX) and sham-operated (sham) rats. At 5 wk after the operation, bone mineral density and serum level of estrogen in OVX rats were lower than those in sham rats. PNA binding sites were found in the odontoblasts in incisors, and the binding sites in OVX rats were much stronger than those in sham rats. Furthermore, PNA binding sites were localized at the predentin matrix in OVX rats, but the reaction in sham rats was not detected. Because D-galactose and N-acetylgalactosamine sugars bound to PNA are important constituents of proteoglycans in dentin matrix and the PNA binding sites reflect the proteoglycan production of odontoblasts, these results indicated that galactosyl glycosylation of proteoglycans in odontoblasts is influenced by estrogen deficiency in rat incisors.

Osteoclasts are present in gp130-deficient mice.

Interleukin (IL)-6, IL-11, leukemia inhibitory factor, and oncostatin M similarly induce osteoclast formation in cocultures of osteoblastic cells and bone marrow cells. These cytokines share a common signal transducer, gp130, which forms a receptor complex with the specific receptor for each cytokine. To investigate the role of gp130 in osteoclast development, we examined bone tissues in gp130-deficient and wild-type newborn mice of the ICR background. Soft x-ray radiographs and microfocus x-ray computed tomographs revealed that bone marrow cavities were present in tibiae and radii of both wild-type and gp130-deficient mice. Microfocus x-ray computed tomography and histological examination demonstrated a decrease in the amount of trabeculae at the metaphysial region in tibiae and radii of the gp130-deficient mice compared with the wild-type mice. The number ofosteoclasts in gp130-deficient mice was about double that in the wild-type mice. There were no apparent differences in the distributions of alkaline phosphatase-positive osteoblasts and the osteoid surface on the trabecular bone at the metaphysial region between the wild-type and gp130-deficient mice. The volume of mineralized trabecular bones was also decreased at mandibulae, accompanied by the increased number of osteoclasts in gp130-deficient mice compared with the wild-type and heterozygous mice. These results suggest that the formation of osteoclasts is not solely dependent on gp130 signaling, at least during fetal development. The osteoclastic bone resorption in gp130-deficient mice may be caused by the functional redundancy of bone-resorbing hormones and cytokines other than those of the IL-6 family.