Long-range and highly sensitive DNase I footprinting by an automated infrared DNA sequencer.

We have shown that an automated DNA sequencer is applicable to fluorescence-based detection of fragments in DNase I footprinting. We demonstrated the potential of long-range and highly sensitive DNase I footprinting taking advantage of an infrared-fluorescence automated DNA sequencer. Footprints of human transcription factor SpI were reproducibly detected ranging approximately between 100 and 750 bp on both strands of an 895-bp DNA fragment in a single electrophoresis run. We developed techniques in data collection and subsequent image processing for highly sensitive detection. Less than 0.1 footprinting unit (fpu: approximately 4.5 ng) of SpI was detected using 3.1 fmol of a 512-bp DNA fragment. This is greater than 10-fold increase in sensitivity over what has previously been reported by visible dye fluorescence DNA sequencers. This method will be very important in systematic analysis of transcription regulatory regions and in large-scale analysis of the transcription process.

Left ventricular end-systolic volume index in patients with ischemic cardiomyopathy predicts postoperative ventricular function.

BACKGROUND: We investigated the usefulness of the preoperative left ventricular end-systolic volume index (LVESVI) as a predictor of postoperative ventricular function. METHODS: We retrospectively reviewed the records of 310 patients who underwent coronary artery bypass grafting and identified 20 patients with ischemic cardiomyopathy with a preoperative ejection fraction less than 0.30. We determined the preoperative and postoperative ejection fraction, LVESVI, and left ventricular enddiastolic volume index using biplane left cineventriculography. Patients were divided into groups depending on whether their preoperative LVESVI was less than 100 mL/m2 (group A, n = 10) or greater than 100 mL/m2 (group B, n = 10). RESULTS: The mean ejection fraction increased significantly after coronary artery bypass grafting in group A from 0.25 +/- 0.05 to 0.40 +/- 0.09 (p < 0.01), but did not change significantly in group B (0.26 +/- 0.05 versus 0.23 +/- 0.06). The mean LVESVI decreased significantly in group A from 83.2 +/- 13.7 to 61.7 +/- 20.4 mL/m2 after operation (p < 0.05), but did not change significantly in group B (124.7 +/- 21.0 versus 121.5 +/- 37.6 mL/m2). In group B, 4 patients had signs of congestive heart failure during the follow-up period and had to be rehospitalized. CONCLUSIONS: The mean ejection fraction improved significantly after coronary artery bypass grafting in patients with a preoperative LVESVI less than 100 mL/m2, despite the presence of a global left ventricular ejection fraction less than 0.30. Our results suggest that the preoperative LVESVI predicts the postoperative status and left ventricular function in patients with ischemic cardiomyopathy.

Left ventricular volume predicts postoperative course in patients with ischemic cardiomyopathy.

BACKGROUND: The left ventricular end-systolic volume index (LVESVI) helps to predict postoperative left ventricular function in patients with ischemic cardiomyopathy. METHODS: We retrospectively assessed the ability of preoperative variables to predict death and the development of postoperative congestive heart failure in 41 patients with a preoperative ejection fraction of less than 0.30. RESULTS: A preoperative LVESVI of greater than 100 mL/m2 was identified as an independent predictor of death by Cox's proportional hazards model. Diabetes and a preoperative LVESVI of greater than 100 mL/m2 were independent predictive risk factors for the development of postoperative congestive heart failure. Postoperative congestive heart failure developed in 2 of the 23 patients (8.7%) who had a preoperative LVESVI of less than 100 mL/m2 and in 10 of the 16 patients (62.5%) who had a preoperative LVESVI of greater than 100 mL/m2. The actuarial survival rate during follow-up in patients who had a preoperative LVESVI of less than 100 mL/m2 was significantly greater than that in patients who had a preoperative LVESVI of greater than 100 mL/m2. The actuarial rate of freedom from congestive heart failure during the follow-up period also was greater in patients who had a preoperative LVESVI of less than 100 mL/m2. CONCLUSIONS: Our results suggest that the preoperative LVESVI predicts the development of postoperative congestive heart failure and the actuarial survival rate in patients with ischemic cardiomyopathy.

[Surgical treatment with infarction exclusion technique and postoperative percutaneous cardiopulmonary support for a patient with ventricular septal perforation--a case report].

A 76-year-old woman was referred to our hospital because of postinfarction ventricular septal perforation (VSP). VSP occurred twelve days after acute myocardial infarction and resulted in interventricular shunt with Qp/Qs of 4.8. Because she suffered from pulmonary edema and oligouria, she underwent emergent surgical treatment after application of the intraaortic balloon pump. The infarction involved whole of right ventricle and the infero-posterior wall of left ventricle, and the location of the perforation was infero-septum with the size of 10 x 6 mm. A bovine pericardial patch was tailored in a triangular shape of approximately 7 x 7 x 5 cm. The base of the patch was sutured to the fibrous annulus of the mitral valve and medial margin of the patch was sewn to healthy septal endocardium. And the lateral side of the patch was sutured to the posterior wall of the left ventricle. Because of difficulty in weaning of the cardiopulmonary bypass, a percutaneous cardiopulmonary support system (PCPS) was inserted via femoral artery and vein with a flow support of 2.0 L/min. After 4 days support of PCPS, improvement of right ventricular function was detected by echocardiogram and PCPS was removed. While PCPS support, low dose heparin to maintain ACT level around 150 seconds was continuously administered. Any complication including bleeding and thrombosis was not remarkable. The patient was discharged on the 53th postoperative day, and is now doing well.

[A case of coronary artery bypass grafting with coronary-coronary bypass for familial hypercholesterolemia].

Coronary artery bypass grafting in a 68-year-old woman with familial hypercholesterolemia and severe calcification of the ascending aorta was successfully performed. The left internal thoracic artery bypassed the left anterior descending artery, the right gastroepiploic artery bypassed the left circumflex artery and the saphenous vein graft bypassed the right coronary artery, the proximal anastomosis was based on segment 1 and the distal anastomosis was on segment 3 of the right coronary artery (coronary-coronary bypass). The operation was performed with aortic no touch technique which consisted of fibrillatory arrest without aortic cross-clamping, and femoral artery perfusion. The post operative angiogram revealed patency of all graft, and she discharged at 20th post operative day. Coronary-coronary bypass was took into consideration in a patient with severe calcification of the ascending aorta and without suitable in situ arterial graft.

[Postoperative follow-up of acute aortic dissection and the result of second operations].

Between January 1990 and March 1998, surgical treatment was performed in 75 patients with acute aortic dissection at Omiya Medical Center. Seventy-three patients (97%) of them were classified type A aortic dissection. Thirteen of them died due to hemorrhage (5 cases), cardiac failure (3 cases), visceral ischemia (3 cases) and others (2 cases) after the operation. Hospital mortality rate was 17.3%. Sixty-two survivors were followed up to 8 years. During the follow up period, five patients died due to pneumonia, gastric cancer, cardiac failure, brain hemorrhage and unknown event. Five-year survival rate including hospital death was 77% evaluated by Kaplan-Meier method. Second operations for the enlargement of residual false lumen with the entry were performed in 4 patients (6.5%) of 62 survivors. Second operations were also performed in other 6 patients referred to us from other hospitals because of the enlargement of false lumen. Nine of them survived (90%) and returned to their daily life.

[Intraoperative assessment of the ascending aorta by echogram during the CABG operation for the prevention of cerebral infarction].

While coronary artery bypass grafting operations (CABG), we started to use the echogram to evaluate the ascending aorta intraoperatively from December 1993. During a period from January, 1990, to June, 1995, 379 patients were treated with CABG. Intraoperative echogram was used in 127 cases (group I) and 252 cases unused (group II). The sites of the aorta for evaluation were following: site of cannulation, aortic clamping, and proximal anastomosis respectively. Depending on the echographical findings the operative procedures were changed as required. The incidence of postoperative cerebral embolism in group I was 0.8% (one patient) and in group II, 2.4% (6 patients). Although no significant difference was found in the cohort, rate of incidence in the group II was high. There were 4 cases who had significant atheromatous lesions clearly evaluated by echogram, which were not detected by palpation. We conclude that the intraoperative assessment of the ascending aorta by echogram is beneficial in prevention of cerebral infarction.

[A case report of St. Jude medical aortic valve prosthesis thrombosis].

We report a case of successful semi-emergent redo aortic valve replacement for thrombosed prosthetic valve. Patient was a 59-year-old male who had undergone aortic valve replacement of St. Jude Medical prosthetic valve and open mitral commissurotomy 14 years ago. He suffered from pneumonia with hemosputum and admitted a neighbor hospital. But he was reffered to our medical center because of progressing dyspnea. We found the immobility of one of the leaflets of the prosthetic valve by cinefuluoroscopy. He was also diagnosed as prosthetic valve thrombosis and mitral valve restenosis using ultrasonic echocardiography. The thrombi were developed on the hinge of one of the leaflets, and they might be formed during the time he had got inappropriate anticoagulation therapy at the former hospital. We emphasise the importance of strict anticoagulation control for the patients valve replaced.

[Pancreas head carcinoma associated with situs inversus viscerum totalis].

The patient was a seventy seven years old male whose chief complaint was jaundice. Chest and abdomen roentgenogram showed situs inversus viscerum totalis. Echographically, pancreas head tumor was showed. Stenosis of inferior bile duct and dilatation of main pancreatic duct were showed by percutaneous transhepatic cholangiography and endoscopic retrograde cholangio pancreaticography. So, pancreas head carcinoma associated with situs inversus viscerum totalis was diagnosed. Pancreaticoduodenectomy and modified Child method was undergone. At the time of operation, liver was recognized left side of abdomen. The tumor was diagnosed well or moderately differentiated papillotubular adenocarcinoma by pathological study. This unusual combination of situs inversus viscerum totalis and pancreas head carcinoma was reported.

[Cerebral infarction after the cardiovascular operation].

From January, 1990 through July 1994, 615 adult patients were undergone cardiovascular operation under the cardiopulmonary bypass. Sixteen patients were suffered perioperative cerebral infarction. The etiology of the cerebral infarction was evaluated on the pre and postoperative brain CT findings by the neurologists. In the 283 coronary artery bypass operations, 4 patients suffered watershed infarction (WS) and 4 cerebral embolism. In the 252 valve operations, one WS and one embolism. In the 80 thoracic aortic operations, 5 WS and one embolism, respectively. The risk factors of WS were the elderly, emergency, the longer operative period, and the longer cardiopulmonary bypass period. The risk factor of the embolism were male, preoperative cerebral infarction, the calcified finding of the ascending aorta by the chest CT. It is important to take preventive strategies against the watershed infarction.

[Clinical significance of selective cerebral perfusion with cold blood on the brain protection].

In 42 patients with thoracic aortic disease, a selective cerebral perfusion with 16 degrees C cold blood was applied for the brain protection during the repair of the thoracic aorta. The surgical repair consisted of the replacement of the ascending aorta (9 cases), the ascending aorta and aortic arch (12 cases), the aortic arch (18 cases), and the aortic arch and descending aorta (3 cases). Twenty-two patients of them (52%) required emergency surgery and four patients died due to postoperative complications including visceral organ ischemia (2 cases) and multiple organ failure (2 cases). The mortality rate of this group was 18.2% (4/22 cases). In elective surgical classes, one patient died due to intraoperative coronary embolism. The mortality rate of this group was 5.0% (1/20 cases). No postoperative obvious brain defect was observed except one old patient (85-year-old female) with ruptured aortic arch who already had the brain infarction preoperatively. She died due to multiple organ failure with unconsciousness. Other patients including the patients with long cerebral perfusion (> 180 min) recovered well and returned to normal daily life. The selective cerebral perfusion with cold blood was easy to prepare and demonstrated the superb efficacy of brain protection in the patient.

DT-diaphorase-like quinone reductase in rat plasma.

The present study provides the evidence that DT-diaphorase-like quinone reductase exists in rat plasma. The quinone reductase activity toward menadione was found in rat plasma in the presence of NADH or NADPH. The enzyme activity was induced by pretreatment with 3-methylcholanthrene, but was not affected by phenobarbital. The 3-methylcholanthrene-induced quinone reductase activity was separated into three fractions (F1, F2, and F3) by gel filtration, which showed NAD(P)H-linked, NADH-linked, and NAD(P)H-linked activities, respectively. F1, which was induced by 3-methylcholanthrene, was inhibited by dicumarol, and cross-reacted with rat liver DT-diaphorase antibody.

Quinone-dependent tertiary amine N-oxide reduction in rat blood.

Rat blood exhibited a significant quinone-dependent N-oxide reductase activity towards imipramine N-oxide. The reduction mediated by the blood proceeded in the presence of both NAD(P)H and menadione under anaerobic conditions. When menadione was replaced with 1,4-naphthoquinone or 9,10-phenanthrenequinone, similar results were obtained. The reduction was also mediated by the combination of rat erythrocytes and plasma. The reducing activity was inhibited by dicumarol and carbon monoxide. When boiled plasma was combined with untreated erythrocytes, the N-oxide reducing activity was abolished. In contrast, when boiled erythrocytes were combined with untreated plasma, the activity was unchanged. These results suggest that the activity is caused by the heme of hemoglobin in erythrocytes and quinone reductase in plasma. In fact, erythrocytes and hemoglobin have the ability to reduce the N-oxide when supplemented with DT-diaphorase purified from rat liver in the presence of both NAD(P)H and menadione. Hemoglobin also exhibits N-oxide reductase activity with reduced menadione (menadiol). Furthermore, hematin exhibits a significant reducing activity in the presence of menadiol. The reduction appears to proceed in two steps. The first step is enzymatic reduction of quinones to dihydroquinones by quinone reductase(s) with NADPH or NADH in plasma. The second step is nonenzymatic reduction of imipramine N-oxide to imipramine by the dihydroquinones, catalyzed by the heme group of hemoglobin in erythrocytes. Cyclobenzaprine N-oxide and brucine N-oxide are similarly transformed to the corresponding amines by the above reducing system in blood. These results suggest that blood plays an important role in the reduction of tertiary amine N-oxides to tertiary amines.

[An emergent surgical case of acute massive pulmonary embolism supported by antithrombotic percutaneous cardiopulmonary support system].

We present an emergent surgical case of massive pulmonary embolism. A 57-year-old male patient was refereed to our medical center for progressive dyspnea. He was intubated because of severe hypoxia. Pulmonary arteriography revealed massive pulmonary embolism. In the catheter laboratory he fell in shock and the heart was arrested, antithrombotic percutaneous cardiopulmonary support (PCPS) was introduced immediately. Emergent thrombectomy was carried out consequently under moderate hypothermic complete cardiopulmonary bypass. Up to 30 x 20 x 10 mm in size fresh clots were removed. Antithrombotic PCPS and IABP were maintained for 168 hours postoperatively. There were no hemorrhagic complication during the support because low dose heparin was administered continuously to keep ACT around 150 sec. He discharged from the hospital two months later and alive in good health. In conclusion, antithrombotic PCPS is very useful to care massive pulmonary embolism with thrombectomy.

[Replacement of descending thoracic aorta using open proximal anastomosis under hypothermic circulatory arrest].

Open proximal anastomosis under hypothermic circulatory arrest was applied to eleven consecutive patients with descending aortic diseases. These patients included five aortic dissections and six thoracic aortic aneurysms. Fourth and 7th intercostal spaces were opened by left posterolateral thoracotomy. Cardiopulmonary bypass was established by right atrial drainage via femoral vein and main pulmonary artery. Arterial blood was perfused via femoral artery. The descending aorta was opened under hypothermic circulatory arrest with anal temperature of 20 degrees C, and the anastomosis of the proximal site of the graft was performed with bloodless field. After the proximal anastomosis was finished, the main graft was clamped and perfused via the branch of the graft. The distal anastomosis was performed during circulatory arrest of the lower body. Mean circulatory arrest time of the upper body was 31 min, and that of the lower body was 37 min. Nine of the patients arrive without any major complications, but two of them died due to postoperative low cardiac output syndrome and postoperative pneumonia. Open proximal anastomosis under hypothermic circulatory arrest may be useful for the replacement of the diseased descending aorta due to dissection or aortic aneurysm with mural thrombi because of the advantage of non-clamping anastomosis with bloodless surgical field.

A combination of preductal aortic coarctation and type B dissection: report of a case.

We present herein the case of a 39-year-old man found to have significant coarctation of the preductal aorta combined with a type B dissection, associated with Marfan's syndrome. This extremely rare pathological combination could be defined preoperatively only by a three-dimensional computed tomography scan. By means of selective cerebral perfusion, the coarctation was resected, and the total aortic arch was replaced with a Dacron graft.