Direct measurement of nitric oxide during experimental cardiopulmonary bypass.

We developed a system to measure nitric oxide (NO) concentration during cardiopulmonary bypass in anaesthetized pigs (n = 6). A T-shaped connector, attached to an NO sensor, was mounted in the extracorporeal circuit at two measuring sites: proximal to the membrane oxygenator (venous side) and distal to the arterial line filter (arterial side). After performing a preliminary validation study, we measured plasma NO concentration before and during total cardiopulmonary bypass circulation (non-pulsatile flow 1.5 l/min) and without pulmonary ventilation. After establishing bypass, PaO2 was 318 - 393 mmHg; when PaO2 was decreased to 80 - 100 mmHg, plasma NO concentration in the arterial circuit fell by 39.2 +/- 15.6 nM. There was no observable change in plasma NO concentration at the venous circuit. This new system could be useful in monitoring NO concentration during cardiac surgery with cardiopulmonary bypass, and for understanding the possible pathophysiological roles of hyper-nitric oxaemia in cardiopulmonary bypass-related cardiovascular complications.

beta2-adrenergic receptor stimulation-induced immunosuppressive effects possibly through down-regulation of co-stimulatory molecules, ICAM-1, CD40 and CD14 on monocytes.

We examined the effects of beta2-adrenergic receptor (beta2-AR) agonists on the expression of co-stimulatory molecules on lipopolysaccharide (LPS)-stimulated human peripheral blood mononuclear cells. The study found that beta2-AR agonists inhibited the expression of intercellular adhesion molecule-1 (ICAM-1), CD40 and CD14 on monocytes, and that AR agonist activity was antagonized by the selective beta2-AR antagonist, butoxamine. The selective beta2-AR agonists salbutamol and terbutaline induced a similar co-stimulatory molecule expression pattern. The LPS-induced production of tumour necrosis factor-alpha was inhibited by AR agonists, and this was also antagonized by butoxamine, and mimicked by salbutamol and terbutaline. The AR agonists also inhibited T-cell proliferation through beta2-AR stimulation. This study clearly demonstrated that endogenous catecholamines elicited immunosuppressive effects through beta2-AR stimulation, possibly due to down-regulation of the expression of ICAM-1, CD40 and CD14 on monocytes. These results suggested that the sympathetic nervous system might regulate the T-helper cell balance via the peripheral end-effectors of the stress system.

[Surgical treatment of thymic carcinomas].

Five cases of surgically treated thymic carcinoma are reported. The patients (4 men and a woman) ranged in age from 46 to 76 years old with a mean of 64.6. Four patients were asymptomatic and an abnormal shadow on X-ray films was noted. One remaining patient suffered from hoarseness. One patient had stage II disease and the others had stage III. Surgical tumor resection was performed in all cases. Only 1 patient among the 5 underwent a successful complete resection. Histological examinations of the resected specimens revealed squamous cell carcinoma of thymus. Four specimens were poorly differentiated and 1 is moderately differentiated carcinoma. All patients received radiation therapy post operatively. Three patients are alive without any recurrence 6, 8 and 109 months after the surgery. Thymic carcinomas are frequently invasive or metastatic at the time of diagnosis. But poorly differentiated group, in squamous cell carcinoma, mucoepidermoid carcinoma and besaloid carcinoma, are characterized by a low incidence of local recurrence and distant metastasis. They also have a good sensitivity for the radiation. Therefore complete surgical resection combined with postoperative radiation therapy should be a choice in treating thymic carcinomas. We considered that complete resection and postoperative radiation therapy is a curative therapy for thymic carcinomas.

Platelet activity of residual blood remained in the cardiopulmonary bypass circuit after cardiac surgery.

AIM: We measured the platelet count and platelet function in residual blood in the cardiopulmonary bypass (CPB) circuit after cpb and compared them with data before CPB operation. METHODS: The subjects included 34 cases of patients subjected to CPB surgery. The residual blood was concentrated by ultrafiltration after CPB, collected in the bag and the platelet count and platelet activity was measured. ADP 2, 5, 10 microM was used as agonists and measurement was made by turbidimetry. RESULTS: The mean value of the platelet count was 18.3+/-5.65x10(4)/mm(3) before surgery and 17.2+/-8.39x10(4)/mm(3) in the residual blood, there is no difference. Concerning the platelet aggregation activity, the maximum aggregation rate decreased significantly with ADP 2 microM from 47.4+/-19.6% before surgery to 27.1+/-17.2% in the residual blood (p<0.01). Likewise, it decreased significantly with ADP 5 and 10 microM. The reduction rate of the platelet aggregation activity was higher in the group of not less than 100 minutes compared with the group of less than 100 minutes, but no significant difference was found. CONCLUSION: Autotransfusing whole blood per se without the "cell saver" treatment is more advantageous to keep hemostasis function after surgery since many platelets having the aggregation activity exist in residual blood in the CPB circuit.

[Ventricular free wall re-rupture after surgical treatment of ventricular free wall rupture due to acute myocardial infarction; report of a case].

An in-hospital 72-year-old male with complaint of anterior chest pain was presented with shock. Pericardial effusion was confirmed by echocardiography, and therefore, he was brought to the operating room immediately with diagnosis of ventricular free wall rupture. The repair was performed using fibrin glue, fibrin sheet, and pericardial patch. His post-operative course was uneventful until massive bleeding came through the chest tube on the 5th day from the initial surgery. The emergency sternotomy was made again for hemostasis. In the re-operation, an approximately 20 mm laceration along the proximal circumflex artery was found and this was successfully repaired with 2 pledgetted horizontal mattress sutures. It is important and necessary to treat a postoperative patient taking care of re-rupture.

[A case of non-small-cell lung cancer successfully treated using combination chemotherapy with CDDP and vinorelbine].

A 67-year-old woman presented to our hospital with a chief complaint of bloody sputum. A plain chest X-ray a CT scan revealed a tumor shadow 3 cm in size in the middle lobe of the right lung, multiple nodular shadows in the bilateral lung fields and enlarged hilar and mediastinal lymph nodes. A tumor biopsy done under bronchoscopy revealed poorly differentiated adenocarcinoma of the lungs (cT2N3M1). She was given two courses of combination therapy consisting of cisplatin (80 mg/m2) and vinorelbine (20 mg/m2). The primary tumor in the middle lobe of the right lung and the lung metastases were markedly reduced in size, and a complete response was obtained. The only adverse events were grade 4 neutropenia and grade 2 nausea and vomiting.

[Combined valvular and coronary artery surgery].

Between 1990 and 1999, 78 patients underwent combined valvular coronary artery operation. Aortic valve disease was present in 49 patients, mitral valve disease in 23 patients, aortic and mitral valve disease in 6 patients. The average age was 67 years. Twelve patients had had a previous myocardial infarction. The average number of grafts inserted was 1.82 per patients, and the average number of artery grafts inserted was 0.96 per patients. The most number of grafts were placed prior to valve replacement or plasty. And periods of myocardial ischemia were kept at a minimum by coronary perfusion through free grafts. Preoperative mortality was 1.3%. And event fee ratio after operation was 95% (mean follow up 42 month). Therefore the operative risk of combined surgery is, in general, low and the long term results are favorable.

[A case report of aneurysm of the ductus arteriosus combined with mitral regurgitation].

A case with the giant aneurysm of the ductus arteriosus combined with severe mitral regurgitation is reported. 58-year-old male underwent MVR and patch closure of the ductal orifice for staged operation. The first operation was MVR and patch closure of the PDA orifice of the pulmonary artery end using retrograde cerebral perfusion (RCP) with deep hypothermic circulatory arrest (DHC). The second operation was performed on 3 months after the first operation using left thoracotomy approach, and patch closure of the ductal orifice via the aorta using RCP with DHC was performed. Upon following-up examination, the patient is now doing well 20 months after the initial surgery.

[Surgical treatment of intracardiac tumors in 25 patients].

For most intracardiac tumors, operation is the only means of therapy. In our institute, we have aggressively performed operation for intracardiac tumors regardless of histological type because resection for tumor had a beneficial effect on the hemodynamics with congestive heart failure. Twenty-five cases of cardiac tumors were operated upon from 1980 through 1998. The follow-up period ranged from 2 months to 19 years. The histological diagnoses of the tumors were as follows: benign tumors 24 (myxoma 21, papillary fibroelastoma 1, fibroma 1, angiomyolipoma 1) and malignant tumor (angiosarcoma 1). There was one hospital death in this series. In the New York Heart Association classification, the cardiac performances of intracardiac benign tumors after operation were Class I or II. The results of surgical treatment of intracardiac benign tumors were satisfactory both in short-term and in long-term. On the other hand the long term result of malignant tumor was extremely poor. A patient with angiosarcoma died 8 months later due to bone metastasis.

[Clinical study of emergency coronary artery bypass surgery].

Between January, 1996 and December, 1998, 29 patients were undergone emergency coronary artery bypass grafting (CABG) in our institute. Age ranged 34 to 85 years (mean 65 +/- 11 years, male:female = 25:4). Of 29 emergency cases, 3 were hospital death. Hospital mortality rate was 10.7%, which was significantly higher than the hospital mortality of elective CABG (1.4%) during the same period. The necessity of IABP before CABG was 72% in emergency cases (elective surgery: 0%). Thus the use rate of arterial grafts were 86.2% in emergency cases (elective surgery: 100%), the patency of the arterial grafts were 100%. It is important to make stable condition of the patients before the operation, and therefore it is important to make contact closely with the cardiologists for making stable condition and for lowering the operative mortality. And, we should use arterial grafts for the long term result as much as possible if it is an urgent operation.

[New screening method for coagulation abnormality including AT III deficiency during CABG].

In our institute, 1 ml of heparin is administered to the patients undergoing CABG before dissection and mobilization of the internal thoracic arteries (ITAs) and/or right gastroepiploic artery (GEA) to prevent possible thrombosis or coagulation tendency. Two patients with AT III deficiency underwent CABG and one of them died. The aim of this study is to know whether ACT check before and after administration of 1 ml of heparin is useful as a screening test of coagulation abnormalities including AT III deficiency. One hundred patients (84 males and 16 females) undergoing CABG were studied. Age ranged from 41 to 79 years (mean 64.8 +/- 8.0 years). One ml of heparin was administered to all the patients before ITAs and/or GEA were dissected and mobilized. ACT was doubly checked before (control ACT: c-ACT) and after (heparinized ACT: h-ACT) administration of heparin. ACT extension was defined as follows: ACT extension = (c-ACT)-(h-ACT). Mean c-ACT was 124 +/- 12 sec., h-ACT 188 +/- 26 sec. and ACT extension 64 +/- 24 sec. There were only 3 cases which ACT extension were less than 30 sec.: two of them were combined with AT III deficiency and the other was due to insufficient administration of heparin. In conclusion, examination of ACT after 1 ml administration of heparin is new, simple and convenient screening method for coagulation abnormalities including AT III deficiency during CABG.

[A case report of intrathoracic aneurysm of left subclavian artery].

A case of intrathoracic aneurysm of the left subclavian artery is reported. The case was 68-year-old male. Chest CT and angiography revealed an aneurysm of left subclavian artery (LSA) located the proximal portion of LSA. The chest was opened by fourth intercostal thoracotomy. We evaluated the intima of distal aortic arch and LSA by introperative direct echography using a small probe (finger tip size). Since there was no calcification or mural thrombi at the distal aortic arch, the aneurysm was resected using partial cardiopulmonary bypass and the orifice of LSA was closed direct suture. LSA was reconstructed with knitted Dacron graft (8 mm). Postoperative course was uneventful.

[Case report of successful treatment of patent ductus arteriosus with severe pulmonary hypertension in an adult].

A 40-year-old man was diagnosed as having PDA with severe PH by cardiac catheterization. We decided that surgery was indicated on the basis of 100% oxygen inhalation test. After 100% oxygen inhalation, left to right shunt changed from 37.8% to 61.5%, Qp/Qs changed from 1.43 to 2.60, and PVR changed from 1,199 dyne/sec/cm5 to 237 dyne/sec/cm5. We decided to perform surgery. Under extracorporeal circulation, PDA was safely closed by triple ligation and was directly closed after pulmonary arteriotomy. The postoperative course was uneventful. Severe PH was greatly improved, pulmonary artery pressure recovering to the normal range, by administering PGE1, prostacyclin (PGI2), and nitroglycerin.

[A case of an adult patient of tetralogy of Fallot having malignant hyperthermia during surgery].

An episode of malignant hyperthermia occurring in a 42-year-old man undergoing hypothermic cardiopulmonary bypass is reported. Malignant hyperthermia is a syndrome initiated by a hypermetabolic state of skeletal muscle. A patient presented for correction of an acyanotic tetralogy of Fallot. The coincidental usage of hypothermic cardiopulmonary bypass obscured the classical presenting sings and symptoms of the malignant hyperthermia. And the disease of tetralogy of Fallot made the syndrome difficult to manage. Although the clinical diagnosis of malignant hyperthermia is difficult to be confirmed, when it is suspected, it is prudent for the case to be initially treated as malignant hyperthermia.

[Coronary artery bypass surgery in patients aged 75 years and older].

Coronary artery bypass grafting (CABG) has been performed for elderly patients with increasing frequency. Several studies have shown that the rate of complications and mortality in elderly patients are higher than in younger ones. This report presents results of CABG in patients over 75 years old. From January 1989 to February 1997, 604 patients underwent CABG, of whom 20 patients (3.3%) were 80-86 years old (group A) and 57 patients (9.4%) were 75-79 years old (group B). We compared these two groups with 100 younger patients (group C). Preoperative use of intraaortic balloon pumping and the emergency operation were more frequent in patients of group A (emergency 45%, IABP 20%). And the proportion of the no blood transfusion procedures was lower in elderly patients (group A 20%, group B 18%, group C 82%). The number of grafts per patient (group A 2.45 +/- 0.62, group B 2.2 +/- 0.6, group C 3.2 +/- 0.6) and the number of arterial grafts (group A 1.25 +/- 0.62, group B 1.25 +/- 0.66, group C 2.1 +/- 0.53) were different between the groups. But CABG in elderly patients was performed with low hospital mortality (group A 0%, group B 0.18%) and significant symptomatic benefit. We conclude that CABG can be performed in elderly patients with acceptable mortality and acceptable quality of life, so patients should not denied operation because of an advanced age.

[A surgical case of total anterior papillary muscle rupture after acute myocardial infarction].

Mitral regurgitation (MR) due to rupture of the papillary muscle is one of the most serious complications of acute myocardial infarction (AMI) as well as ventricular septal perforation and ventricular free wall rupture. We experienced a case of complete rupture of the anterior papillary muscle. A 68-year-old man experienced an episode of dyspnea. Electrocardiographic findings were consistent with postero-lateral infarction. Massive MR is present on color Doppler imaging. He was transferred to our hospital for urgent operative indication because of papillary muscle rupture due to AMI. Six hours after the onset, the operation was performed with intra-aortic balloon pump in place. The anterior papillary muscle was ruptured completely in the mid portion. He underwent a mitral valve replacement with a SJM prosthetic valve. There is a few cases with successful urgent surgery for a complete rupture of anterior papillary muscle.

Leiomyoblastoma and leiomyomatosis of the small intestine in a case of von Recklinghausen's disease.

A 70-year-old patient with von Recklinghausen's neurofibromatosis 1 (NF1) developed a stomach ulcer and underwent a total gasterectomy. During the laparotomy, a leiomyoblastoma and multiple leiomyomas, which were histologically diagnosed as such later, were found in the small intestine and resected. It is quite possible that the association of gastrointestinal leiomyomas and NF1 is more than coincidental. It is thus important to take this complication into account in clinical treatment of patients with NF1.

Sialyl Lewis(a) ganglioside in pancreatic cancer tissue correlates with the serum CA 19-9 level.

CA 19-9 ganglioside antigen was extracted from the tumors of 16 patients with pancreatic cancer and the antigen was confirmed by mass spectrometry to be a sialyl Lewis(a) ganglioside. Ductal adenocarcinomas from four patients, two whose Lewis blood phenotype was Le(a- b-), one with undifferentiated carcinoma, and one with an acinar cell carcinoma, did not contain detectable amounts of sialyl Le(a) ganglioside. A significant correlation was found between serum CA 19-9 levels and the recovery of ganglioside antigen from respective tumors, but not tumor burden.