Endoscope disinfection using chlorine dioxide in an automated washer-disinfector.

Although 2% glutaraldehyde is often the first-line agent for endoscopic disinfection, its adverse reactions are common among staff and it is less effective against certain mycobacteria and spore-bearing bacteria. Chlorine dioxide is a possible alternative and an automated washer-disinfector fitted with this agent is currently available. This study was conducted to evaluate the effectiveness of chlorine dioxide in endoscopic disinfection after upper gastrointestinal examination. In vitro microbicidal properties of chlorine dioxide solutions were examined at high (600 ppm) and low (30 ppm) concentrations against various microbes including Pseudomonas aeruginosa, Helicobacter pylori, Mycobacterium avium-intracellulare and Bacillus subtilis in the presence or absence of bovine serum albumin (BSA). Immediately following endoscopic procedures and after application to the automated reprocessor incorporating chlorine dioxide at 30 ppm for 5 min, endoscopic contamination with infectious agents, blood, H. pylori ureA gene DNA and HCV-RNA was assessed by cultivation, sensitive test tape, polymerase chain reaction (PCR) and reverse transcriptase-PCR analysis, respectively. Chlorine dioxide at 30 ppm has equivalent microbicidal activity against most microbes and faster antimicrobial effects on M. avium-intracellulare and B. subtilis compared with 2% glutaraldehyde, but contamination with BSA affected the microbicidal properties of chlorine dioxide. Endoscopic contamination with microbes, blood and bacterial DNA was eliminated after application of the automated reprocessor/chlorine dioxide system. Thus, chlorine dioxide is a potential alternative to glutaraldehyde. The use of automated reprocessors with compatibility to chlorine dioxide, coupled with thorough pre-cleaning, can offer effective, faster and less problematic endoscopic disinfection.

[Surgical strategies for aortic valve disease in elderly patients].

Population of elderly people is increasing and aortic valve disease due to degeneration with aging process, especially aortic stenosis (AS) is increasing in elderly patients. With development and great use of non-invasive diagnostic techniques, particularly echocardiography, the diagnosis and evaluation of aortic valve disease are even safer in these patients. Aortic valve replacement (AVR) is effective treatment for symptomatic AS, however, generally has a higher risk in elderly patients, especially 80 years and over patients. Several reports demonstrated acceptable operative mortality and morbidity in elderly patients. We performed AVR or AVR with other cardiac surgical procedures in 16 cases of 80 years and over patients from 1998 to 2004, and there were no operative or hospital death. Therefore, AVR in 80 years and over patients could be acceptable surgical treatment and age alone is not contraindication.

[Preoperative evaluation for lung resection using right ventricular hemodynamic functions by unilateral pulmonary arterial occlusion test].

We performed a unilateral pulmonary arterial occlusion (UPAO) test for the preoperative evaluation of right ventricular functions as a loading test in patients undergoing a lung resection without cardiac complications preoperatively. We investigated the relationship between changes in right ventricular hemodynamic functions and postoperative cardiac complications, namely right heart failure or arrhythmia. To evaluate the right ventricular hemodynamic function test, we measured the mean pulmonary arterial pressure, cardiac index, right ventricular ejection fraction end-diastolic volume, and stroke volume before and during the UPAO test using the thermodilution method, and calculated the total pulmonary vascular resistance and right ventricular stroke work indexes. The incidence of postoperative cardiac complications was not related to the changes in the total pulmonary vascular resistance index. However, the postoperative cardiac complications were common in patients whose right ventricular end-diastolic volume index was increased by more than 20% during the UPAO test. These results suggest that the changes in the right ventricular end-diastolic volume index during the UPAO test can predict postoperative cardiac complications in patients undergoing a pulmonary resection.

[Surgically repaired bilateral giant bullae after long-time follow-up; report of a case].

A 44-year-old male was admitted to our hospital owing to severe dyspnea of sudden onset. Chest X-ray disclosed bilateral giant bullae. His pulmonary function was severely depressed. VC (%) was 2.61 l (66.3%) and FEV1% (%) was 1.47 l (64.5%). Indication of surgical repair of giant bullae are; space occupying lesion more than 25-50% in 1 thorax, progressive dyspnea, enlargement over time irrespective of symptoms, and expectation that re-expand the normal lung. He was conducted two-staged bullectomy using video-assisted thoracoscopic surgery (VATS) with small incisions. First operation was performed to left lung. Pulmonary function improved. VC (%) increased 3.02 l (76.8%) and FEV1% (%) 2.36 l (76.6%). After second operation, which was performed to right lung, VC (%) was 2.40 l (60.5%) and FEV1% (%) was 2.21 l (92.1%). Hugh-Jones grade improved class IV to class I. Postoperative course was uneventful and he was discharged 15 days after second operation. Two-staged bullectomy was appropriate in this case, because he might have suffered from re-expansion pulmonary edema after first surgery. The extent of recovery of pulmonary function was unpredictable. And performing right lung bullectomy just after the left bullectomy may be dangerous, because the patient have to receive anesthesia with his resected left lung. There is some possibility that patient who has bilateral giant bullae shows severe dyspnea during the progress, care should be taken to conduct operation as soon as possible.

Magnetic noise rejection in the MCG using independent component analysis.

In magnetocardiogram (MCG) measurements, the magnetic noise from any magnetic wire, used to suture the sternum after heart surgery, becomes a problem. As one method of noise rejection, independent component analysis is seen here to be effective. In this study, MCG measurements were carried out under conditions where a wire was attached to a normal subject, also where no wire was attached. Signal processing by independent component analysis was carried out in order to reduce the effect of magnetic noise from the wire. From the comparison of the waveforms after this signal processing and the waveforms where the wire was not attached, it was apparent that the magnetic noise from the wire was reduced. Thus, we have shown that independent component analysis is effective for the reduction of magnetic noise from a magnetic wire, in MCG measurements.

[Arrhythmias newly provoked by exercise training in patients who underwent cardiac surgery].

We investigated the incidence and the varieties of arrhythmia during exercise training in patients who underwent cardiac surgery. Subjects were 1293 patients who underwent cardiac surgery and enrolled our cardiac rehabilitation program. According to the charts and cardiac rehabilitation records, we evaluated the incidence and the varieties of arrhythmia provoked by exercise training in patients after cardiac surgery retrospectively. The arrhythmias related to the exercise training were provoked in 12 times, and the incidence was only 0.09% (12/13646). Atrial fibrillation was the most common arrhythmia, and the incidence was 41.6% (5/12) in these patients. Moreover, these arrhythmias occurred within 2 weeks after surgery. Although most patients recovered to the sinus rhythm spontaneously, 3 patients needed medical treatment or cardioversion. We concluded that the arrhythmia provoked by exercise training in patients after cardiac surgery were rare, non-fatal, and common in the early recovery phase after surgery. However, the supervised exercise training was required in those patients, particularly in early recovery phase of cardiac surgery.

Perioperative serum procalcitonin concentrations in patients with acute aortic dissection.

We investigated the perioperative serum procalcitonin (PCT) concentrations in 5 consecutive patients who underwent surgery for acute aortic dissection (2 men, 3 women; mean age 72 +/- 9 years, age range 52-81 years). Surgery used cardiopulmonary bypass with deep hypothermic circulatory arrest. Blood samples were taken prior to surgery, upon arrival in the intensive care unit, and 6, 12, 18, 24, and 48 h after intensive care unit arrival. Prior to surgery, the PCT level was 4.2 +/- 3.4 (range 0.8-8.3) ng/ml. The PCT increase was greatest at 24 h (5.8 +/- 4.5 ng/ml). Preoperatively, the C-reactive protein concentration was 8.0 +/- 8.3 (range 0.9-23.8) mg/dl, and the white blood cell count was 8.5 +/- 3.1 x 10(3). C-reactive protein continued to increase at 48 h, while the white blood cell count peaked at 24 h. In spite of no symptoms of infectious diseases or septicemia, all patients had a significant preoperative PCT elevation. This finding may have something to do with the specific preoperative condition of acute aortic dissection. However, more clinical investigation is needed to clarify the PCT changes during and after surgery for acute aortic dissection.

Midterm results of conservative repair of the incompetent bicuspid aortic valve.

AIM: Repair of the bicuspid aortic valve is not generally considered the treatment of choice. Our success with this procedure leads us to report our immediate and mid-term METHODS: From August 1993 to December 2000, 19 patients with aortic regurgitation due to congenital aortic valve underwent aortic valve repair (17 men and 2 women with a mean age of 42+/-17 years; range, 16 to 70 years). The mean preoperative aortic regurgitation grade was 3.1+/-0.8 on a scale of 1 to 4. Mean preoperative New York Heart Association functional class was 1.9+/-0.8. Fourteen patients had pure aortic regurgitation, 2 also had infectious endocarditis, 1 had angina pectoris, and 2 had an ascending aortic aneurysm. RESULTS: There was 1 hospital death (5.2%), and 1 patient required re-operation due to recurrent infectious endocarditis. Mean aortic regurgitation grade at discharge was 1.1+/-0.9, and functional class was 1.1+/-0.2. All patients were followed for a mean duration of 40+/-23 months (range, 0.5 to 84 months). There was 1 late death, and two patients required aortic valve replacement. The 5-year survival rate was 90+/-7%. The 1- and 5-year re-operation-free rates were 87+/-12% and 76+/-23%. CONCLUSIONS: Bicuspid aortic valve repair is a safe procedure with good early postoperative RESULTS: However midterm results are not satisfactory. Re-operation is a promising alternative and progress aortic regurgitation were complications. Bicuspid aortic valve repair to valve replacement that requires additional study to individualize treatment.

[Aortic valve repair with minimal access "J" sternotomy].

Recently many cardiovascular operations have been performed with minimally invasive cardiac surgery (MICS). It is reported that MICS is superior to standard full sternotomy in regard to cosmetic and post-operative recovery. In our institution, aortic valve repair operations have been performed to aortic valve insufficiency. This time, we performed aortic valve repair by minimal access "J" sternotomy. A 63-year-old male with degenerative aortic regurgitation underwent aortic valve repair by MICS. He had experienced dyspnea on exertion 7 days before admission. Preoperative transthoracic echocardiogram showed the grade of aortic regurgitation (AR) was severe. Surgery was successful and the grade of AR became trivial. This combined procedure have merits for patients because of freedom from anticoagulation and small incision. Such combined surgery may be indicated in the treatment in a subset of patients with degenerative AR.

[Valvular heart surgery in osteogenesis imperfecta].

Osteogenesis imperfecta is a disease in which fragile bones readily cause fracture. Valvular disease concurrently develops. However, the surgery-related mortality rate is approximately 30%. In this study, we report 2 patients with osteogenesis imperfecta who underwent valvular heart surgery. Patient 1 was a 31-year-old male. He had previously been diagnosed as having osteogenesis imperfecta. Echocardiography suggested aortic valve insufficiency, and aortic valve replacement was performed. Patient 2 was a 59-year-old male. During admission, osteogenesis imperfecta was diagnosed. Echocardiography suggested mitral valve insufficiency, and mitral valve plasty was performed. In the 2 patients, intraoperative hemorrhage was marked. However, there were no fatal complications. We also reviewed the literature.

Selection of surgical methods for infected infrarenal abdominal aortic aneurysms.

BACKGROUND: There is no standard treatment for patients with infected abdominal aortic aneurysm (AAA). To determine the basis for selection of a surgical method, we reviewed our experiences with all patients who underwent surgery for infected infrarenal AAA. METHODS: Between 1993 and 2000, 6 patients with infected infrarenal AAA underwent surgery. Extra-anatomic bypass grafting was performed in 2 of 3 patients with infection extending into the retroperitoneum. In situ grafting was performed in 3 patients with localized infection and in 1 patient with extended infection. RESULTS: Severe peritonitis occurred in 2 patients with extended infection in the early postoperative phase. One patient, who had undergone in situ grafting, died of sepsis. The other patient, who had undergone extra-anatomic bypass grafting, was treated by continuous irrigation with an electrolyzed strong acid aqueous solution (ESAAS). He recovered gradually and was discharged. After a follow-up period with a mean of 40 months (range: 17-102 months), all 5 patients who survived surgery are alive and asymptomatic. CONCLUSIONS: It was suggested that the method used for revascularization should be selected based on the degree of diffusion of infection. For a patient with extended infection, postoperative continuous irrigation with ESAAS appears to be effective in eradicating retroperitoneal infection.

[Redo coronary artery bypass grafting using the patent left internal thoracic artery graft as an in flow with composite internal thoracic artery Y grafting; report of a case].

In redo coronary artery bypass grafting (CABG), graft selection and revascularization methods are major problems. We experienced a redo-CABG with occluded previous vein grafts. These grafts were to the circumflex artery and right coronary artery. We conducted operation using cardiopulmonary bypass. We at this operation, chose right internal thoracic artery (RITA) as a conduit and anastomosed it to the side of functioning left internal thoracic artery (LITA) graft, and then diogonal branch, posterolateral branch, and atrioventricular branch were revascularized with the RITA. Post operative course was uneventful. Internal thoracic artery (ITA) is superior to vein graft and other arterial graft as to long term patency. We believe composite Y graft with the use of bilateral ITA can be one of the revascularization strategy in redo CABG.

[Giant coronary artery aneurysm in diagonal artery; report of a case].

We report a giant coronary artery aneurysm occurred in the diagonal artery. A 44-year-old woman was referred to our institution for further examination of chest X-ray abnormality. Computed tomography revealed a 6 cm intracardiac mass adjacent to pulmonary artery. Cardiac catheterization revealed a giant coronary artery aneurysm with the large thrombus in the diagonal artery. A giant aneurysm 6 cm in diameter was exposed through a median sternotomy. Under beating heart with cardiopulmonary bypass, the aneurysm was opened and organized thrombus was removed. The influx and efflux of the aneurysm were identified and ligated. Under arrested heart with cardioplegia, the diagonal artery was bypassed with the left internal thoracic artery. Finally the aneurysm was obliterated with the running suture. The patient discharged at the 17th postoperative day without any complications. Histologic evaluation of the resected aneurysm revealed atherosclerotic change, destruction of vascular layers and infiltration of inflammatory cells. These findings suggested previous history of coronary arteritis. The coronary aneurysm in this case might be resulted from Kawasaki disease.

Sesquiterpenoids from the fruits of Ferula kuhistanica and antibacterial activity of the constituents of F. kuhistanica.

Ethyl acetate extracts of the air-dried fruits of Ferula kuhistanica afforded three daucane esters: kuhistanicaol H, I and J, together with nine other known compounds. Their structures were established on the basis of spectroscopic evidence. Isolated compounds in this paper and previously reported compounds from the roots and stems of F. kuhistanica were tested for antibacterial activity. Some of them were selectively toxic against Gram-positive bacteria, including methicillin-sensitive and methicillin-resistant Staphylococcus aureus (MSSA and MRSA).

Aortic valve repair of congenital bicuspid aortic valve associated with aneurysm of the ascending aorta.

Two unusual cases of congenital bicuspid aortic valve associated with aneurysm of the ascending aorta are reported. One patient with a 7-cm ascending aortic dilatation and aortic regurgitation (AR) (II/IV), and another with a 6-cm ascending aorta and AR (III/IV), presented for treatment. Replacement of the ascending aorta and aortic valve repair were performed in both cases. Aortic valve repair included resection of the raphe, leaflet plication and subcommissural annuloplasty. Both patients had satisfactory results in the early postoperative period. Despite the promising outcomes after surgery in these patients, long-term changes in valve function and durability remain unknown. Additional close observation and monitoring are required before the procedure can be recommended as the standard of care.

Aortic valve repair in dominant aortic regurgitation.

OBJECTIVE: We studied immediate and mid-term results after aortic valve repair. METHODS: Immediate and mid-term results were studied in 63 patients undergoing aortic valve repair, calculating survival and reoperation free rates. RESULTS: Subjects were 49 men and 14 women aged 15 to 76 years (mean: 53 +/- 17 years). Mean preoperative aortic regurgitation grading of 1 to 4 was 3.2 +/- 0.7. Mean preoperative New York Heart Association functional class was 1.9 +/- 0.8. Two in-hospital deaths occurred. (3.2%) Mean aortic regurgitation grade at discharge was 1.3 +/- 0.8 (p < 0.0001; vs preoperative grade) and functional class was 1.1 +/- 0.2 (p < 0.0001; vs preoperative class),--significantly improved. Overall follow-up was 98.4%, and mean follow-up continued 41.4 +/- 22.1 months. Mean functional class at follow-up was 1.2 +/- 0.4 (n = 49), improved from preoperative class (p < 0.0001). Mean aortic regurgitation grading at follow-up was 1.8 +/- 0.8 (n = 41), improved from preoperative grading (p < 0.0001). Five-year survival was 95.1 +/- 2.8%. One-year reoperation freedom was 96.6 +/- 2.4% and 5-year 77.9 +/- 6.9%. CONCLUSIONS: Survival after surgery was good, while reoperation was comparable to other reports but less satisfactory compared to reoperation freedom after aortic valve replacement. Based on reoperative findings, a change in indication was made. We believe technical refinements could improve postoperative results.

Farnesyl hydroxybenzoic acid derivatives from Ferula kuhistanica.

Four new farnesyl hydroxybenzoic acid derivatives, kuhistanols E-H (1-4), were isolated from the roots of the Uzbekistan medicinal plant Ferula kuhistanica. The structures of the new compounds were elucidated based on spectroscopic and chemical evidence.

[Mitral valve repair--indication and late results].

In recent years, mitral valve repair has become more widespread because it promises a reduction in both mortality and morbidity compared with valve replacement. As the incidence of rheumatic valve disease has declined in Japan, degenerative disease has become the most common cause of mitral regurgitation (MR), for which repair techniques can be successfully applied. The standard repair techniques, including artificial chordal implantation, increase the indications for valve repair to up to 95% of patients with MR and improve the long-term results. The indications for surgical intervention in patients with MR have evolved. Asymptomatic patients are considered for surgery when left ventricular function begins to deteriorate or atrial arrhythmias appear.

Phenylnaphthalene compounds from the subterranean part of Vitex rotundifolia and their antibacterial activity against methicillin-resistant Staphylococcus aureus.

A careful investigation of the subterranean part of Vitex rotundifolia has shown that this plant contains five novel lignans having a 1-phenylnaphthalene-type skeleton together with four known lignans. These structures were elucidated on the basis of spectroscopic data. Furthermore, some of the isolated compounds showed antibacterial activity against methicillin-resistant Staphylococcus aureus (MRSA).