[Off-pump coronary artery bypass grafting for angina pectoris with coronary artery aneurysm due to kawasaki disease: report of a case].

We report a 27-year-old woman who underwent off-pump coronary artery bypass grafting (OPCAB) for angina pectoris with coronary artery aneurysm due to Kawasaki disease. At the age of 3, she was diagnosed as Kawasaki disease with coronary artery aneurysms in the right coronary artery and the left anterior descending artery. She was medically followed-up since then Because an enlarged aneurysm and a stenotic lesion were recognized in the right coronary artery, operation was indicated. In operation, the right coronary artery was ligated at the inflow and the outflow of the aneurysm. OPCAB was also conducted with the right internal thoracic artery anastomosed to the right coronary artery. Postoperative course was uneventful, and she was discharged at the day 5 after operation. Revascularization using arterial grafts, especially the internal thoracic arteries, may be the choice for young patients to expect a good patency rate in the long-term.

[Off-pump coronary artery bypass grafting as standard operation; surgical strategies and results].

We report the clinical results of 799 cases of isolated coronary artery bypass grafting (CABG) performed during the recent 5 years. We performed off-pump CABG (OPCAB) as standard operation, in which arterial grafts were mainly used. The mean number of distal anastomoses was 3.6 +/- 1.4 per patient Four hundred and fifty-five cases (57.0%) were done only with arterial grafts. Bilateral internal thoracic arteries were used in 326 cases. The mean number of saphenous vein grafts was 1.6 +/- 0.8 per patient. Continuous hemodiafiltraion (CHDF) was performed in 22 cases (2.8%) postoperatively. Among the OPCAB cases, 10 cases (1.3%) were converted to on-pump CABG. There were 7 cases (0.9%) of hospital death. The mean length of postoperative hospital stay was 10.2 +/- 5.3 days. The ratio of the patients with left main trunk disease and that of the patients who required postoperative CHDF increased year by year. The mean length of postoperative hospital stay decreased every year, and the reduced length was 2.7 days in the 5 years (8.7+/- 3.6 days in 2007). It is expected that patients who have severe calcified lesions or who are on hemodialysis may increase in the near future. In such cases, CABG rather than percutaneous catheter intervention may be suitable for revascularization. Therefore, not only appropriate choice of treatment strategies, but also accurate surgical techniques may become more importance.

Thoracoscopic cardiomyoplasty: a canine feasibility study.

BACKGROUND: Thoracoscopy may be effective in reducing the surgical stress of cardiomyoplasty. The feasibility of thoracoscopy in cardiomyoplasty was investigated. METHODS: Cardiomyoplasty by thoracoscopy and by the open method through a thoracotomy was performed in dogs. After 8 to 10 weeks of preconditioning, the hemodynamic effect of burst stimulation was measured. RESULTS: Cardiomyoplasty by thoracoscopy took 90 +/- 21 minutes (mean +/- standard deviation), whereas cardiomyoplasty by the open method took 67 +/- 10 minutes (p < 0.05). As a result of burst stimulation, aortic pressure, descending aortic flow, and left atrial pressure increased by 15.1% +/- 6.5%, 8.6% +/- 6.3%, and 3.8% +/- 4.6%, respectively, in the dogs that received the cardiomyoplasty by thoracoscopy, whereas those indices increased by 16.5% +/- 6.9%, 9.8% +/- 5.9%, and 4.8% +/- 4.2%, respectively, in dogs that received cardiomyoplasty by the open method. No significant difference between the two groups was shown in any index. CONCLUSIONS: Cardiomyoplasty by thoracoscopy was technically practical, and its hemodynamic effect was similar to that of the open method. The feasibility of cardiomyoplasty by thoracoscopy was thereby suggested.

A survey on noise exposure level in an aluminum can production plant.

The present investigation was designed to quantify noise exposure of laborers at various sections of an aluminum can production plant. The acoustic environment in each area was described by sound pressure level (SPL). Decibel (dB) readings were taken for a range of individual frequencies and weighting scales (A and C). Speech interference level (SIL) values for laborers in different production sections were also determined. Moreover, by means of a personal noise dosimetry technique, the equivalent continuous noise exposure level (dB(A)) during an 8-h shift (Leq, 8) was computed. The results obtained were as follows. Spectral analysis of the noise indicated that high SPL associated with high frequency noise exceeded the permissible limit against hearing damage, and it generally amounted to levels higher than 90 dB(A), whereas those inside the control rooms were in the range of 54-60.5 dB(A). Assessment of the results obtained from personal noise dosimeters also revealed that the Leq,8 values were higher than the prescribed limit (85 dB(A)). By preliminary audiometric examinations on the right ears of workers, hearing threshold shifts (HTS) were noticed in the range of 7-11 dB at 1 kHz and 12-16 dB at 4 kHz. With regards to the SIL values (93.2-96.5 dB(A)) which were more than the maximum vocal effort, communication between workers and/or with supervisor were appraised to be very difficult (shouting) or impossible. It was concluded that (a) the dB readings observed in this survey indicate a potentially serious possibility of hearing disability, even though high level of HTS could not be noticed in the preliminary audiometric test, and (b) the risk of accidents should also be taken into account regarding the nonauditory effects of such a high level of noise. We suggest that (1) minimizing the transmission of noise through acoustical countermeasures need to be considered, and (2) introducing a schedule comprising on-time and off-time could be beneficial in a workers' health conservation program.

[A successful repair of aortic regurgitation and right ventricular aneurysm long after correction of tetralogy of Fallot].

Twenty-seven years after correction of tetralogy of Fallot, a 35-year-old man, suffered from dyspnea on effort and palpitations, underwent repair of aortic regurgitation and right ventricular aneurysm. Aortic regurgitation was due to a perforation at the base of the right coronary cusp, probably caused during the initial VSD patch closure, and it was repaired by suture. The right ventricular aneurysm was excised and the defect was closed directly. After operation, only slight aortic regurgitation was observed and premature ventricular contractions, presumably related to right ventricular aneurysm, were decreased markedly. His postoperative course has been uneventful and satisfactory for these 15 months.

Recent insights into human coronary collateral development.

Enhancement of coronary collateral function is an intriguing approach to the preservation of ischaemic myocardium. Coronary collateral development consists of collateral recruitment and collateral growth. Collateral growth encompasses proliferation of capillaries in the ischaemic area (angiogenesis) and maturation of pre-existing collateral vessels (arteriogenesis), with the latter being more relevant in humans. Therefore, treatment intended directly for arteriogenesis of collateral vessels appears to be more effective. Promotion of coronary collateral growth has many attractive features, particularly in patients with angina who are not indicated for percutaneous coronary intervention or coronary artery bypass grafting surgery. A complete elucidation of the remaining practical and mechanistic questions of arteriogenesis may lead to a new remedy capable of developing collateral vessels more effectively.

[Cardiomyoplasty effectiveness: review of the mechanism].

The effectiveness of cardiomyoplasty on cardiac function is discussed, and the four mechanisms proposed to explain cardiomyoplasty effectiveness are reviewed. The first such mechanism, termed the squeezing effect, suggests that skeletal muscle wrapped around the heart squeezes the heart in the same way as cardiac massage, resulting in direct improvement in cardiac function. Hemodynamic improvement is rarely detectable, but significant subjective improvement is commonly seen clinically. The second mechanism, termed the sparing effect, suggests that even if cardiac performance remains unchanged after cardiomyoplasty, contraction of the wrapped lattisimus dorsi muscle causes an increase in the slope of the end-systolic pressure-volume relationship, and a reduction in left ventricular wall stress. Myocardial oxygen consumption is thereby reduced. The third mechanism, called the girdling effect, suggests that cardiomyoplasty may act like an elastic girdle around the heart to prevent enlargement of the failing heart. The fourth mechanism, called the collateral effect, suggests that, when applied to the ischemic heart, cardiomyoplasty increases collateral blood flow to the myocardium, thereby benefiting cardiac function. However, the existence of unknown mechanisms is suggested by two phenomena that cannot be explained by these four mechanisms alone. Cardiomyoplasty was introduced as a method of direct cardiac assistance. However, it now appears that the relatively passive role of cardiomyoplasty in oxygen consumption saving and ventricular enlargement prevention may be of great importance.

Use of tactile stiffness to detect fatigue in the latissimus dorsi muscle.

In clinical settings, no method has been established to examine the fatigue of a latissimus dorsi muscle (LDM) preconditioned for cardiomyoplasty. We examined the feasibility of measuring muscle stiffness (tactile stiffness) to evaluate muscle fatigue in situ using our tactile sensor. We stimulated canine LDM with burst pacing and monitored both stiffness and tension to determine their relationship. In both dissected LDM and LDM in situ, the decrements of these parameters during burst pacing were compared between preconditioned and unconditioned LDM. In measurement in situ, the sensor probe was placed on the LDM through a small incision. Strong statistical correlation was shown between stiffness and tension (r = 0.935). In decrements of stiffness in situ, there were statistically significant differences between preconditioned and unconditioned LDM. Our tactile sensor system can provide an efficient method for evaluating fatigue of muscles in situ without measuring muscle tension.

Myocardial ischemia enhances the expression of acidic fibroblast growth factor in human pericardial fluid.

Acidic fibroblast growth factor (FGF) is a potent mitogen that can induce angiogenesis in vivo. We have recently reported a marked increase of basic FGF in the pericardial fluid of patients with severe coronary stenosis and an increase in vascular endothelial growth factor (VEGF) in the pericardial fluid of patients with severe myocardial ischemia. The purpose of this study was to evaluate whether acidic FGF levels in the pericardial fluid are associated with severe myocardial ischemia. Immediately after incision of the pericardium in 48 patients during open-heart surgery, 3-5ml of pericardial fluid was obtained. Concentrations of basic FGF and VEGF in the pericardial fluid were measured using an enzyme-linked immunosorbent assay (ELISA). The ELISA system for human acidic FGF was newly developed using a rabbit antibovine acidic FGF antibody. The patients were divided into three groups (group A: 13 patients undergoing emergency coronary artery bypass grafting (CABG) for unstable angina; group B: 17 patients undergoing elective CABG for stable angina; group C: 18 patients undergoing nonischemic open-heart surgery). The VEGF level in the pericardial fluid in group A was 68 +/- 59pg/ml, which was significantly higher than 33 +/- 9 pg/ml in group B and 31 +/- 20 pg/ml in group C (P < 0.05). The concentrations of basic FGF in the pericardial fluid in groups A and B were 722 +/- 601 and 773 +/- 763pg/ml, respectively, significantly higher than 263 +/- 349pg/ml in group C. The pericardial acidic FGF level in group A was 4,291 +/- 2,336 pg/ml, which was also significantly higher than 2,386 +/- 1,048 pg/ml in group B and 2,589 +/- 990 pg/ml in group C (P < 0.05). The acidic FGF level correlated well with the level of VEGF (r = 0.61, P < 0.0001). It is concluded that the level of acidic FGF in pericardial fluid is associated with severe myocardial ischemia. This result indicates that the release of acidic FGF from the myocardial tissue into pericardial fluid is closely related to severe myocardial ischemia.

Increased pericardial fluid concentrations of the mature form of adrenomedullin in patients with cardiac remodelling.

BACKGROUND: There is evidence that adrenomedullin has autocrine or paracrine activities that oppose cardiac remodelling. However, it remains unclear whether it exerts those local functions in heart failure patients. OBJECTIVE: To investigate the relation between plasma and pericardial fluid concentrations of adrenomedullin and left ventricular haemodynamic variables. DESIGN: Samples of plasma and pericardial fluid were obtained from 50 patients undergoing cardiac surgery. They were classified into two groups: group N (n = 27) with a left ventricular end diastolic volume index (LVEDVI) < or = 90 ml/m(2); and group R (n = 23) with LVEDVI > 90 ml/m(2). Plasma and pericardial fluid concentrations of total adrenomedullin (tAM) and mature adrenomedullin (mAM) were measured and related to the preoperative haemodynamic variables. RESULTS: Pericardial fluid concentrations of mAM were much higher than the plasma concentration in both group N and group R (mean (SEM), 10.6 (1.7) v 3.3 (0.2) fmol/ml, p = 0.0001; and 21.2 (2.8) v 3.9 (0.3) fmol/ml, p < 0.0001, respectively). The ratio mAM/tAM in pericardial fluid was significantly higher than in plasma (0.56 (0.02) v 0.28 (0.02), p < 0.0001). Pericardial fluid concentrations of mAM, but not plasma concentrations, were significantly correlated with LVEDVI, left ventricular end systolic volume index, left ventricular ejection fraction, and left ventricular mass index (r = 0.60, 0.63, -0.54, and 0.47, respectively). CONCLUSIONS: Raised pericardial fluid concentrations of mAM may reflect the actions of adrenomedullin as a local mediator against cardiac remodelling in patients with left ventricular dysfunction.