Improving the success rate of human corneal endothelial cell cultures from single donor corneas with stabilization medium.

Main objective of this study was to improve the success rate of human corneal endothelial cell (hCEC) cultures from single donor corneas. We could show that the use of stabilization medium prior to cell isolation may have a positive effect on the success rate of hCEC cultures from single research-grade donor corneas by allowing growth of otherwise possibly not successful cultures and by improving their proliferative rate. hCEC were obtained from corneo-scleral rims of 7 discarded human research-grade cornea pairs. The Descemet membrane-endothelium (DM-EC) sheets of each pair were assigned to 2 experimental conditions: (1) immediate cell isolation after peeling, and (2) storage of the DM-EC sheet in a growth factor-depleted culture medium (i.e. stabilization medium) for up to 6 days prior to cell isolation. hCEC isolated by enzymatic digestion were then induced to proliferate on pre-coated culture plates. The success rate of primary cultures established from single donor corneas were higher for DM-EC sheets kept in stabilization medium before cell isolation. All cultures (7/7) initiated from stabilized DM-EC sheets were able to proliferate up to the third passage, while only 4 out of 7 cultures initiated from freshly peeled DM-EC sheets reached the third passage. In addition, for the 4 successful paired cultures we observed a faster growth rate if the DM-EC sheet was pre-stabilized prior to cell isolation (13.8 ± 1.8 vs 18.5 ± 1.5 days, P < 0.05). Expression of the phenotypical markers Na+/K+-ATPase and ZO-1 could be shown for the stabilized cultures that successfully proliferated up to the third passage.

Thromboangiitis obliterans (Buerger's disease) in women.

Thromboangiitis obliterans (TAO), or Buerger's disease, is a distinct clinicopathologic entity. It is a relatively uncommon cause of occlusive peripheral vascular disease. The disease is more prevalent in some geographic areas than in others, and there is a probable ethnic predisposition. Buerger's disease is decidedly rare in women; only 24 cases with histologic proof of the disease have ever been recorded, including 12 new cases described in this article. The clinical presentation and histopathology of TAO in women differ in no way from that in men. There is no evidence that the disease is milder in women, since 9 of the 12 in this series underwent amputation and the remaining 3 required reconstructive and bypass surgical intervention. Awareness of the entity and familiarity with the clinical, angiographic, and pathologic features of the disease are the key to a prompt and correct diagnosis of Buerger's disease.

Takayasu arteritis. A study of 32 North American patients.

Thirty-two patients (26 female, 6 male) with angiographically diagnosed Takayasu arteritis were seen at the Mayo Clinic between 1971 and 1982. Racial composition of this group was 23 North American Caucasians, 4 Mexicans, 3 Orientals, 1 Native American, and 1 patient of Middle Eastern origin. Incidence of the disease in Olmsted County, Minnesota, was 2.6/million/year. Diagnosis was often delayed for long periods of time, with a median delay of 18 months. Patients had both non-vascular symptoms (arthralgias in 56%, fever in 44%, weight loss in 38%) and symptoms of vascular stenosis such as arm claudication (47%) and hypertension due to renal artery stenosis (41%). All patients had either multiple vascular bruits (94%) or absent pulses (50%). Laboratory findings included anemia (44%) and elevations of erythrocyte sedimentation rate (78%). Almost all patients had multiple sites of arterial involvement documented by angiogram with various combinations of stenosis, luminal irregularity and aneurysm formation. Response to corticosteroid treatment was usually very good, with dramatic improvement in non-vascular symptoms and return of pulses in 8 of the 16 patients with absent pulses prior to treatment. Five-year survival rate from time of diagnosis was 94%. Twelve patients underwent surgical procedures involving the carotid arteries (5 cases), subclavian artery (4 cases) and renal arteries (3 cases). Three aneurysms were resected, one had aortic valve replacement for severe aortic regurgitation, and two patients underwent transluminal angioplasty. Pathologic changes were restricted to the media and adventitial layers of the vessel wall and were indistinguishable from those of giant-cell or temporal arteritis. Takayasu arteritis is more common than previously suspected in North America, is not restricted to any one racial group, and is readily treatable with corticosteroids and surgical vascular reconstruction.

Catastrophic antiphospholipid syndrome. Clinical and laboratory features of 50 patients.

We analyzed the clinical and laboratory characteristics of 50 patients with catastrophic antiphospholipid syndrome (APS) (5 from our clinics and 45 from a MEDLINE computer-assisted review of the literature from 1992 through 1996). Thirty-three (66%) patients were female and 17 (34%) were male. Twenty-eight (56%) patients had primary APS, 15 (30%) had defined systemic lupus erythematosus (SLE), 6 (12%) had "lupus-like" syndrome, and 1 (2%) had rheumatoid arthritis. Mean age of patients in this series was 38 +/- 14 years (range, 11-74 yr). Three (6%) patients developed the clinical picture of catastrophic APS under the age of 15 years, and 11 (22%) were 50 years old or more. In 11 (22%) patients, precipitating factors contributed to the development of catastrophic APS (infections in 3, drugs in 3, minor surgical procedures in 3, anticoagulation withdrawal in 2, and hysterectomy in 1). The presentation of the acute multi-organ failure was usually complex, involving multiple organs simultaneously or in a very short period of time. The majority of patients manifested microangiopathy--that is, occlusive vascular disease affecting predominantly small vessels of organs, particularly kidney, lungs, brain, heart, and liver--with a minority of patients experiencing only large vessel occlusions. Thrombocytopenia was reported in 34 (68%) patients, hemolytic anemia in 13 (26%), disseminated intravascular coagulation in 14 (28%), and schistocytes in 7 (14%). The following antibodies were detected: lupus anticoagulant (94%), anticardiolipin antibodies (94%), anti-dsDNA (87% of patients with SLE), antinuclear antibodies (58%), anti-Ro/SS-A (8%), anti-RNP (8%), and anti-La/SS-B (2%). Anticoagulation was used in 70% of the patients, steroids in 70%, plasmapheresis in 40%, cyclophosphamide in 34%, intravenous gammaglobulins in 16%, and splenectomy in 4%. Most patients, however, received a combination of nonsurgical therapies. Death occurred in 25 of the 50 (50%) patients. In most, cardiac problems seemed to be the major cause of death. In several of these, respiratory failure was also present, usually due to acute respiratory distress syndrome and diffuse alveolar hemorrhage. Among the 20 patients who received the combination of anticoagulation, steroids, and plasmapheresis or intravenous gammaglobulins, recovery occurred in 14 (70%) patients. The use of ancrod and defibrotide appeared to be effective in the 2 respective patients in whom they were used.

Status of the coronary arteries at necropsy in diabetes mellitus with onset after age 30 years. Analysis of 229 diabetic patients with and without clinical evidence of coronary heart disease and comparison to 183 control subjects.

Clinical and morphologic observations were made in 229 necropsy patients with diabetes mellitus (DM) with onset of diabetes mellitus after 30 years of age--65 without (DM-CHD) and 164 with (DM + CHD) clinical evidence of coronary heart disease (CHD). These observations were compared to those in 183 age-sex-matched nondiabetic control subjects who died from a fatal coronary event (CHD-DM). The average number of three major (right, left anterior descending, left circumflex) coronary arteries per patient narrowed > 75 percent in cross-sectional area by atherosclerotic plaques was identical in the 229 diabetic patients (DM-CHD and DM + CHD) and in the control subjects (CHD-DM), namely, 2.5/3.0. This similarity in the amount of coronary arterial narrowing was present irrespective of the age at onset (after 30 years) or duration of diabetes mellitus. The DM + CHD patients had more severe narrowing of the three major coronary arteries than did the DM-CHD patients (p < 0.01). The amount of severe narrowing in the proximal halves of each of these three arteries was similar to that in the distal halves. The amount of severe (> 75 percent in cross-sectional area) narrowing of the left main coronary artery was greater in the patients with diabetes mellitus than in the nondiabetic controls: 13 percent versus 6 percent (p < 0.01). The type of treatment received by the patients with diabetes mellitus or their adherence to the therapeutic program as measured by the level of random fasting blood sugar did not alter the amount of severe coronary narrowing observed at necropsy.

Catecholamine-secreting paraganglioma of the interatrial septum.

A 29-year-old woman was found to have clinical and biochemical evidence of a functioning paraganglioma (pheochromocytoma) five years after the onset of symptoms. Despite extensive investigation of known potential sites of paragangliomas (including laparatomy), the suspected tumor eluded localization. Adrenergic blocking agents controlled her blood pressure but did not affect the other manifestations of catecholamine excess. Ischemic perforation of the colon and refractory gram-negative sepsis resulted in death. At autopsy, a large paraganglioma was found within the heart; the unique tumor location was an important factor in the fatal clinical course.

Mesenteric inflammatory veno-occlusive disease. A seldom recognized cause of intestinal ischemia.

We describe seven patients (three men, four women; ages 27-78) who presented with signs of intestinal ischemia requiring surgical intervention. In each case, the resected colon, small bowel, or both showed striking phlebitis and venulitis affecting veins of the bowel and mesentery and resulting in ischemic injury of the bowel. In each case, this vasculopathy was the only demonstrable cause of ischemia. Arteritis involving the bowel or the mesentery was not found in any patient, and none had clinical evidence or a history of extraintestinal vasculitis. The composition of the inflammatory infiltrate was variable; in four patients, it was predominantly lymphocytic, in two necrotizing and in one lymphocytic/granulomatous. In addition, three patients also had myointimal hyperplasia of the affected mesenteric veins. Six of seven patients recovered uneventfully after surgery, suggesting a self-limited or indolent process, and the seventh died of an unknown cause. We propose the name mesenteric inflammatory veno-occlusive disease (MIVOD) to describe this unusual and previously unrecognized cause of intestinal ischemia. Its etiology is unknown, and MIVOD may represent a precursor of the recently described idiopathic myointimal hyperplasia of mesenteric veins.

Diffuse pulmonary hemorrhage. An uncommon manifestation of Wegener's granulomatosis.

We report two cases of Wegener's granulomatosis with the unusual manifestation of diffuse alveolar hemorrahge. One patient with well-documented Wegener's granulomatosis developed alveolar hemorrhage 4 weeks after leukopenia necessitated the discontinuation of cyclophosphamide. The second patient presented with pulmonary hemorrhage and died 10 days after an open-lung biopsy in which histologic features of Wegener's granulomatosis were overshadowed by alveolar hemorrhage. Lung biopsies in both cases showed marked alveolar hemorrhage and pulmonary capillaritis. The importance of recognizing capillaritis and other subtle histologic features of Wegener's granulomatosis are emphasized.

Energy dose for ventricular defibrillation of children.

Transthoracic direct current shock is the recommended treatment for ventricular fibrillation in children as in adults. To determine the appropriate energy dose, data were collected from 71 defibrillation attempts in 27 children. Sixty-three of the 71 shocks (89%) were successful in terminating fibrillation. Fifty-seven shocks were within 10 watt-seconds (w-sec) above or below an energy dose of 2 w-sec/kg of body weight. Fifty-two (91%) of these were effective and five (9%) were ineffective. In every case, fibrillation was ultimately terminated by a shock of 4 w-sec/kg or less. The results of these studies suggest that an energy dose of 2 w-sec/kg (or approximately 1 w-sec/lb) is adequate to defibrillate most children weighing under 50 kg. We currently use 2 w-sec/kg and double the energy dose if the first defibrillation attempt is unsuccessful.

Centenary of the first correct antemortem diagnosis of coronary thrombosis by Adam Hammer (1818--1878): English translation of the original report.

William Heberden (1710--1801), in 1768, described angina pectoris, the classic symptom of ischemic heart disease, 150 years after the discovery of the coronary circulation by William Harvey (1578-1657). Another 110 years had elapsed before the first antemortem diagnosis (confirmed at autopsy) of coronary thrombosis was reported by Adam Hammer in 1878. The patient was a 34 year old man who died some 19 hours after a sudden collapse. Although the patient's clinical features were atypical (such as the absence of angina and the presence of complete heart block) and the autopsy showed vegetative aortic endocarditis that appeared to be causally related to the thrombotic coronary occlusion, Hammer's astute and carefully reasoned bedside diagnosis was history-making and deserves to be so recognized.

Pathologic anatomy of Ebstein's anomaly of the heart revisited.

The typical textbook description of Ebstein's anomaly of the heart usually singles out and emphasizes the downward displacement of septal and posterior leaflets of the tricuspid valve. An anatomic reappraisal of this uncommon anomaly suggests that other structural abnormalities of import should be equally stressed. Among the 15 well preserved autopsy specimens in this series, enlargement of the right atrioventricular (A-V) junction and malalignment of the giant and sometimes muscularized anterior leaflet of the tricuspid valve were consistently found. In addition, massive aneurysmal dilation of the right ventricle was present in almost two thirds (9 of 15) of the hearts. Our observations raise the possibility that abnormal embryonic development of the right A-V junction may be the primary event that leads to malformation of the tricuspid valve apparatus.

Cholesterol pericarditis terminating as constrictive calcific pericarditis. Follow-up study of patient with 40 year history of disease.

This is a follow-up report of a patient with idiopathic cholesterol pericarditis (previously described in this Journal in 1961). The patient had had recurrent pericardial effusions since 1939, and died with calcific constrictive pericarditis some 40 years later. In the interim, the patient had an extended period (17 years) of symptomatic relief after pericardiotomy in 1958.

Reduction of thrombosis in canine coronary bypass vein grafts with dipyridamole and aspirin.

The potential benefit of platelet inhibitor drugs in reducing early thrombosis of coronary arterial vein bypass grafts was assessed in dogs. There were 26 control dogs and 24 dogs treated with dipyridamole, 55 mg/day plus aspirin, 325 mg/day. The dogs in both groups were killed at 2 hours and 1, 2, 3, 7 and 14 days after operation. The grafts were perfused with fixative in vivo, harvested and examined with light microscopy. Severe alterations of the graft wall were observed in the dogs in both groups. The grafts in the control group had a high incidence rate of thrombosis, which occurred early after the operation; those in the treated group had a significantly reduced incidence of thrombosis (p = 0.025). Our study indicates that a combined regimen of dipyridamole and aspirin is effective in reducing early graft thrombosis in dogs.

Surgical significance of the coronary arterial anatomy in truncus arteriosus communis.

In truncus arteriosus communis, as in other anomalies of conotruncal development, the coronary arterial anatomy not only differs from that found in the normal heart but also is subject to unpredictable variations. A consistently distinctive pattern was found in roughly two thirds of 31 cases, a frequency approximating that with which a distinctive coronary arterial pattern occurs in complete transposition of the great vessels. Surgical injury to a major coronary artery was identified in 2 of the 30 hearts from patients with truncus arteriosus communis who died in the early postoperative period. Of particular significance are large branches of the right coronary artery crossing the upper anterior surface of the right ventricle to supply the anterobasal surface of both ventricles and the upper part of the interventricular septum. These arteries are at special risk in surgical procedures utilizing a conduit anastomosed to a right ventriculotomy.

Reduction of intimal thickening in canine coronary bypass vein grafts with dipyridamole and aspirin.

The potential benefit of platelet inhibitor drugs on coronary arterial bypass vein grafts was assessed in dogs with magnification-corrected angiographic luminal measurements and quantitative histologic evaluation of the vein grafts. There were 11 control animals and 11 animals treated with dipyridamole, 55 mg/day, plus aspirin, 325 mg/day. Eighteen animals with patent grafts were studied when electively killed 2, 4 or 6 months after grafting. At 14 days, there was greater angiographic narrowing in the most distal 1 cm of vein grafts in control than in treated dogs (P less than 0.01). This same angiographic narrowing persisted in control dogs until they were killed (P less than 0.03). Computer-assisted measurements of the entire area of intimal thickening were done on vein graft cross sections taken 1 cm from the distal anastomosis. The circumference of the vein grafts at the intimal-media junction was measured from the same section and the potential maximal luminal area calculated. The calculated luminal narrowing due to intimal thickening was greater in control than in treated dogs (P less than 0.03). These data correlate well with the demonstrated angiographic narrowing. The findings indicate that the degree of early intimal thickening that persists 2 to 6 months postoperatively in canine coronary bypass vein grafts may be reduced by the platelet inhibitor combination of dipyridamole plus aspirin.

Vein graft patency and intimal proliferation after aortocoronary bypass: early and long-term angiopathologic correlations.

To determine the clinical significance of intimal proliferation as a cause of aortocoronary bypass vein graft obstruction, 492 vein grafts from 281 patients were studied 0 to 75 months postoperatively. All grafts had been inserted between 1968 and 1975 by one surgeon using one technique. The graft patency rate was 92 percent (55 to 60) in the first month; 91 percent (49 of 54) at 1 to 3 months; 84 percent (37 to 44) at 4 to 6 months; 77 percent (33 of 43) at 7 to 12 months; 81 percent (113 of 140) at 13 to 24 months; 82 percent (59 of 72) at 25 to 36 months; and 84 percent (66 of 79) at 37 to 75 months. Vein graft samples were obtained from 41 patients: In 27 patients with 51 grafts (early group), they were obtained 0 to 30 days (mean 14 days) postoperatively; in 14 patients with 27 grafts (late group) they were obtained 7 to 75 months (mean 34 months) postoperatively. Intimal proliferation was graded 1 to 4 corresponding to an intima/media thickness ratio of 1,2,3 or 4, respectively. In the early group, all 51 vein grafts howed grade 1 to 2 intimal proliferation; 5 of these grafts were occluded, all as a result of recent thrombosis. In the late group, 17 of the 27 grafts were studied histologically. All patent vein grafts showed grade 2 to 3 intimal prolferation. Four vein grafts were occluded but only one as a result of grade 4 intimal proliferation. In 14 patients in the late group, angiograms performed shortly before vein graft samples were obtained revealed 14 patent and 4 occluded vein grafts. Ten of the 14 patent vein grafts showed grade 2 to 3 intimal proliferation but were of uniformly good caliber angiographically (graft/artery ratio more than 1.5).

Anatomy of coronary arteries in univentricular hearts and its surgical implications.

The coronary arterial anatomy in 26 univentricular hearts, its relation to the morphologic characteristics of the ventricles and rudimentary chambers, and its surgical implications were analyzed. All of the hearts except two had been operated on; 18 had septation with or without an extracardiac conduit and 6 had had palliative procedures. Twenty-one univentricular hearts with a left ventricular type main chamber had an anterior outlet chamber (17 left-sided subaortic, 3 right-sided subaortic and 1 right-sided subpulmonary). Right and left delimiting arteries outlined the outlet chamber in 16 hearts (76 percent). In 20 of the 21 hearts, large delimiting parallel branches of the right coronary artery course over the anterior wall of the heart; 13 of these vessels had been injured surgically with resultant ischemic myocardial necrosis. Five univentricular hearts did not have an outlet chamber; two had a left ventricular type main chamber and three had a morphologically right ventricular main chamber. Three of the five hearts had rudimentary pouches, located anteriorly in one and posteriorly in two. The two rudimentary pouches lying posteriorly were not outlined by delimiting arteries. Two of the five univentricular hearts without an outlet chamber also had injured coronary arteries. Thus, the identification of outlet chambers and rudimentary pouches in univentricular hearts is facilitated by the determination of coronary anatomy. The presence of major delimiting parallel branches over the usually favored ventriculotomy sites renders them vulnerable to surgical injury; such mishaps occurred in 15 of the 24 hearts that had either corrective or palliative operations.

Pulmonary hypertension and familial Mediterranean fever: a previously unrecognized association.

Familial Mediterranean fever is an autosomal recessive inherited disorder characterized by recurrent episodes of fever accompanied by inflammation of the peritoneum, pleura, synovial membranes, and skin. The disorder predominantly affects persons of Mediterranean origin. The most serious complication of the disease is amyloidosis, which is the cause of death in a substantial proportion of adult patients with the disorder. Only one previous report has described pulmonary hypertension in a patient with systemic amyloidosis associated with multiple myeloma. Herein we describe the first known occurrence of pulmonary hypertension due to pulmonary amyloidosis in a 48-year-old woman with familial Mediterranean fever. Postmortem examination showed extensive deposits of amyloid in the pulmonary vessels, alveolar capillary walls, and myocardium, which explained the hypoxia, hypotension, and terminal cardiac arrhythmias that were the immediate cause of death in this patient.

Pathology of the senescent heart: anatomic observations on 237 autopsy studies of patients 90 to 105 years old.

Persons older than 85 years of age will constitute the fastest growing segment of the US population in the next decade, and despite the recent decline in mortality from heart disease, cardiovascular disease remains the single greatest cause of death in these elderly persons. We studied the pathologic changes in the hearts of 237 patients (93 men and 144 women) who had lived to the age of 90 years or older. The degree and extent of coronary atherosclerosis in these senescent hearts were similar to findings reported in younger patients who died of coronary heart disease, but calcification of the coronary arteries, mitral annulus, and aortic valve was more prevalent, as was cardiac amyloidosis. Multiple cardiac disorders were common in these very elderly hearts, but they seemed to play a lesser role in precipitating heart failure or shortening the life-span of the patients. Important factors in attaining longevity seem to be protection from the development of severe coronary artery disease by an unexplained mechanism and an innate resistance to cardiac dysfunction from a multitude of structural changes that occur with advancing age.

The right ventricular myocardium in Ebstein's anomaly: a morphometric histopathologic study.

Ebstein's anomaly of the tricuspid valve is associated with right ventricular dilatation in approximately two-thirds of cases. Dilatation may be massive. It involves not only the right ventricular wall proximal to the tricuspid valve (atrialized ventricle) but also the right ventricle distal to the valve (funtional right ventricle), including the right ventricular infundibulum. For further definition of the pathogenesis of dilatation of the functional right ventricle (distal chamber), a morphometric histopathologic study was performed on 10 hearts with Ebstein's anomaly and 10 normal age-matched control hearts. In the group with Ebstein's anomaly, five hearts exhibited dilated ventricles and five did not. The study demonstrated that dilatation of the right ventricle in Ebstein's anomaly was associated not only with thinning of the wall but also with an absolute decrease in the number of myocardial fibers counted through the thickness of the wall from endocardium to epidcardium.