Peripheral T cell cytotoxicity predicts the efficacy of anti-PD-1 therapy for advanced non-small cell lung cancer patients.

Anti-programmed cell death-1 (PD-1) therapy exerts beneficial effects in a limited population of cancer patients. Therefore, more accurate diagnostics to predict the efficacy of anti-PD-1 therapy are desired. The present study investigated whether peripheral T cell cytotoxicity predicts the efficacy of anti-PD-1 therapy for advanced non-small cell lung cancer (NSCLC) patients. Advanced NSCLC patients treated with anti-PD-1 monotherapy (nivolumab or pembrolizumab) were consecutively enrolled in the present study. Peripheral blood samples were subjected to an analysis of peripheral T cell cytotoxicity and flow cytometry prior to the initiation of anti-PD-1 therapy. Peripheral T cell cytotoxicity was assessed using bispecific T-cell engager (BiTE) technology. We found that progression-free survival was significantly longer in patients with high peripheral T cell cytotoxicity (p = 0.0094). In the multivariate analysis, treatment line and peripheral T cell cytotoxicity were independent prognostic factors for progression-free survival. The analysis of T cell profiles revealed that peripheral T cell cytotoxicity correlated with the ratio of the effector memory population in CD4+ or CD8+ T cells. Furthermore, the results of flow cytometry showed that the peripheral CD45RA+CD25+/CD4+ T cell ratio was higher in patients with than in those without severe adverse events (p = 0.0076). These results indicated that the peripheral T cell cytotoxicity predicted the efficacy of anti-PD-1 therapy for advanced NSCLC patients.

Histological analysis of trabeculotomy - An investigation on the intraocular pressure lowering mechanism.

The primary aim of trabeculotomy (TLO) and/or minimally invasive glaucoma surgery (MIGS) is to produce a direct communication between the anterior chamber (AC) and collector channels (CC), which is believed to be the process by which intraocular pressure (IOP) is normalized. However, we previously reported our finding of the large opening of the Schlemm's canal (SC) into the AC in eyes with failed TLO (Amari et al., 2015). If the routes from the AC to the CC by TLO/MIGS are direct, IOP should be stabilized at around aqueous vein pressure if the SC and CC are undamaged. However, in eyes in which TLO/MIGS is successful, IOP usually stays at around the middle or high teens post surgery. In this current study, we retrospectively investigated the specific reason for middle- or high-teens IOP following TLO/MIGS via the histological examination of trabeculectomy (TRAB) specimens that include the area of previous TLO/MIGS in eyes with failed TLO or insufficient IOP control following TLO by specifically focusing on the behavior of the SC endothelium (SCE). Patient background, maximum IOP prior to TLO/MIGS and TRAB, the number medications administered, and elapsed time between TLO/MIGS and TRAB were reviewed. In 42 TRAB specimens of 31 120-180° TLO eyes (Group A; 27 ab-externo and 4 ab-interno eyes) and 11 360° suture TLO eyes (Group B), SC length (SCL), the site of the incision in the trabecular meshwork (TM) [i.e., the center (CEN)/anterior-tip (TIP)], and TM opening into the AC [i.e., open (OPN)/closed (CLS)] were histologically investigated. The correlation between the clinical parameters of the maximum IOP of pre-TLO/MIGS, the maximum IOP of pre-TRAB, the percentage of IOP reduction (PIR), and the histological results were statistically evaluated. Our findings revealed a significant negative correlation between the maximum IOP of pre-TRAB and SCL (P = 0.0167), and a significantly higher PIR in the eyes with OPN than those with CLS in Group A (P = 0.0045). However, no significant difference in SCL was found between the OPN and CLS eyes in both groups. In comparison to Group A, a higher percentage of OPN (82%) yet a smaller SCL (P = 0.0024) was observed in Group B. No significant correlation between clinical and histological parameters was found in Group B. In both groups, the common finding was sealing of the SC openings by SC endothelium (SCE) and no direct communication between the AC and the CC. This fact indicates that the nature by which SCE seals off the opened SC lumen into the AC created by TLO may be very important for maintaining the blood-aqueous barrier. Based on these results, we concluded that accessibility for aqueous humor to the SC and preservation of the SC may be important for lowering IOP by TLO. However, the opening of the SC into the AC (OPN type) does not guarantee an adequate IOP lowering effect if the SC is widely collapsed. Thus, TLO may be improved only by eliminating the most resistant part of the TM with minimal SCE damage.

Noninferiority of Microhook to Trabectome: Trabectome versus Ab Interno Microhook Trabeculotomy Comparative Study (Tram Trac Study).

PURPOSE: To elucidate the noninferiority of ab interno microhook trabeculotomy (µTLO) using a recently developed reusable stainless spatula-type microhook device to incise the trabecular meshwork to Trabectome (Neomeix, Inc) surgery in terms of the 1-year postoperative outcomes of Japanese patients with glaucoma by means of propensity score analyses. DESIGN: Multicenter, retrospective cohort study. PARTICIPANTS: We enrolled 553 and 392 patients who underwent Trabectome surgery and µTLO, respectively, between January 2014 and March 2020 at 10 facilities. METHODS: Logistic regression analysis was conducted to calculate the propensity score, which indicates the likelihood of treatment assignment (Trabectome or µTLO). We set the following factors as outcome-related covariates: age, sex, facility, glaucoma disease types, preoperative intraocular pressure (IOP), glaucoma drug score, mean deviation of Humphrey visual field test results, antithrombotic drug use, the presence or absence of combined cataract surgery, and incision range of the trabecular meshwork (1 or 2 quadrants). We analyzed 4 different methods (matching, inverse probability of treatment weighting [IPTW], stratification, and regression adjustment) using the propensity score. We set 15% as the noninferiority margin based on previous Trabectome meta-analysis results. MAIN OUTCOME MEASURES: The primary outcome was surgical success at 1 year after surgery. We defined surgical success as satisfying all 3 criteria: (1) IOP within 5 to 21 mmHg, (2) IOP reduction of 20% or more from preoperative IOP, and (3) no additional glaucoma surgery. RESULTS: The 95% confidence interval of risk difference of surgical failure in µTLO in reference to Trabectome surgery was -12.1% to +9.5% in matching, -12.7% to +11.1% in IPTW, -12.2 to +7.0 in stratification, and -9.7% to +8.1% in regression adjustment, all of which fell within the predetermined noninferiority margin of 15%. CONCLUSIONS: Surgical success of µTLO at 1 year after was not inferior to that of Trabectome surgery.

"De-airing" in open heart surgery: report from the CVSAP nation-wide survey and literature review.

Since the beginning of cardiac surgery, retained intracardiac air has been an important problem. While transesophageal echocardiography enabled to visualize the air and de-airing procedures have been routinely done, they appear to vary much among institutions not necessarily based on firm scientific evidence. Thus, "de-airing" was chosen as the theme of 2016 CVSAP (cardiovascular surgery and anesthesia and perfusion) symposium and a nation-wide questionnaire survey was carried out prior to it. This paper reports on its results and illustrate "the best of de-airing" based on literature review. The collection rate of the questionnaire survey was 77.9% (278/357) and 83.3% (85/102) from the major institutions of surgeons and anesthesiologists, respectively. More than 90% of both consider de-airing as important, since adverse events of air embolism were actually encountered including critical ones. Most routinely performed de-airing procedures are posture change, lung inflation and aspiration through the vent cannulae. Direct aspiration is performed in one-third of institutions. Carbon dioxide insufflation is performed in 82.5% of institutions (mostly 2-3 L/min). However, not a few surgeons are skeptical for its significance. While many surgeons are grateful for collaboration by anesthesiologists, some expect more information sharing between them. They also expect that clinical engineers understand "de-airing" better and operate the extracorporeal circulation system appropriately to avoid an occurrence of undesirable event. Some surgeons anticipated a convenient device for de-airing. Furthermore, some questions to be solved in the future were raised, including how meticulously the bubbles should be removed or how efficient carbon dioxide insufflation is.

The Correlation Between Aqueous Humor Flow and IOP Before and After Trabectome: Developing a Grading System to Quantify Flow.

INTRODUCTION: To develop a grading system that provides objective quantification of flow through the conventional aqueous humor outflow (AHO) system. The technique gives clinicians an additional assessment option in the evaluation of glaucoma treatment approaches. METHODS: This was a retrospective observational study. This study evaluated the eyes of all primary open-angle glaucoma patients who underwent a Trabectome (NeoMedix Corp., Tustin, CA, USA) procedure with or without cataract surgery in the interval between April and September 2016 (n = 73). The nasal hemisphere was divided into three regions. Utilizing a four-level grading system designed for this study, an aqueous humor outflow grade (G0-G3) was assigned to each region using a video taken during examinations. The individual grade levels of the three regions were combined to get a composite AHO score. The correlation between the composite AHO score and intraocular pressure (IOP) was then analyzed. Additionally, the speed of red blood cell (RBC) clusters in the episcleral veins (ESV) was calculated when made possible by the existence of pulsatile flow. RESULTS: At 3 months following the Trabectome procedure, average IOP decreased from 26 to 15 mmHg. Assessment of the relationship between AHO grade and IOP demonstrated that a high composite AHO score was correlated with lowered IOP (Tukey-Kramer method p < 0.05). Additionally, it was found that if one of the three regions had an AHO grade of ≥ G2, an IOP of < 20 mmHg could be predicted. (Fischer's exact test p < 0.0001). Calculated speed was as follows: at G1, the speed was 0.68 ± 0.26 mm/s (n = 7), at G2, the speed was 1.8 ± 0.84 mm/s (n = 5), and at G3, the speed was 6.8 ± 3.3 mm/s (n = 6). CONCLUSION: There was a significant correlation between an increase in the composite AHO score and a decrease in IOP. Additionally, the speed of RBC clusters as they traveled through the ESVs remained consistent for each of the grades, and the span of the speeds from lower to higher grades represented a significant range. These findings suggest that the grading system is a reliable measure of AHO. TRIAL REGISTRATION IDENTIFIER: UMIN 000031745.

Distal aortic arch aneurysm in an adult case of PHACE syndrome.

A rare case of adult PHACE syndrome with a distal aortic arch aneurysm was treated surgically. The patient had several anomalies including uneven cerebral blood flow, a small left common carotid artery and a narrowed transverse aorta. Under deep hypothermic circulatory arrest, aortic replacement with reconstruction of the left subclavian artery was performed uneventfully. Cystic degeneration of the tunica media was observed in the aneurysm wall.

A rotating cerium anode X-ray system allows visualization of intramural coronary vessels after cardiac stem cell therapy for myocardial infarction.

Conventional angiography is insufficient for evaluating the therapeutic effect of cardiac regeneration therapy. A microangiographic X-ray system using a cerium anode was developed. Cerium has a characteristic X-ray with a peak at 34.6 keV, which allows visualization of tiny amounts of iodine. The performance of the cerium anode X-ray system was evaluated in two excised normal canine hearts and in excised ischemic canine hearts treated with c-kit-positive cardiac stem cells (5 canines) or without cells (5 control canines). In the normal canines, branches penetrating from the left anterior descending artery into the myocardium were visualized, down to third-order branches. In just the treated hearts treated with stem cells, small vessels characterized by irregular vessel walls were observed. The cerium anode X-ray system allowed visualization of microvessels in excised ischemic canine hearts, and may evaluate the effect of cardiac stem cell therapy.

The SYNTAX score is correlated with long-term outcomes of coronary artery bypass grafting for complex coronary artery lesions.

OBJECTIVES: We analysed retrospectively the long-term outcomes of conventional coronary artery bypass grafting (CABG) as employed routinely for complex coronary lesions by observing patients with low (0-22), intermediate (23-32) and high (≥33) SYNTAX scores. The purpose of this study was to evaluate the correlation between the SYNTAX score and long-term major adverse cardiac and cerebrovascular events (MACCEs) including all-cause death, stroke, myocardial infarction (MI) and repeat revascularization after CABG. METHODS: The study enrolled 396 consecutive patients with stable and untreated left main and/or three-vessel disease, who had been referred to our heart team from 2000 through 2009. They all routinely underwent conventional CABG. The three groups (low score; n = 159, intermediate score; n = 150, high score; n = 87) were compared, looking at the primary endpoint of MACCE and its components. We also analysed the effects of diverse variables on long-term MACCEs after the operation. RESULTS: The cumulative 10-year MACCE rates in patients with low, intermediate and high SYNTAX score were 25.3, 35.8 and 48.1%, respectively. The Kaplan-Meier cumulative event curves showed a significantly higher MACCE rate after CABG in patients with a higher SYNTAX score than in those with a lower score (log-rank P = 0.0012). This was mainly because of a significantly increased rate of repeat revascularization in the higher SYNTAX score group (log-rank P = 0.0032). The cumulative rate of repeat revascularization at 10 years in patients having low, intermediate and high SYNTAX score were, respectively, 4.6, 15.7 and 16.8%. The cumulative rates of the combined outcomes of death/stroke/MI at 10 years did not show statistical differences between the three groups (22.3% with low, 25.0% with intermediate and 38.4% with high score, log-rank P = 0.063). In the multivariable analysis, the SYNTAX score [hazard ratio (HR) 1.03, P = 0.0043] and logistic EuroSCORE II (HR 1.34, P = 0.0012) were found to be significant predictors of long-term MACCEs. CONCLUSIONS: The SYNTAX score is correlated with long-term outcomes, in terms of MACCEs, after conventional CABG for complex coronary lesions and is prognostic of long-term outcomes of CABG for patients with complex lesions.

Long-term outcomes and risk analyses of coronary bypass for left main disease.

BACKGROUND: We retrospectively analyzed the long-term outcomes and risk predictors of conventional coronary artery bypass grafting routinely employed for patients with left main disease. METHODS: From January 2000 through December 2009, conventional coronary artery bypass grafting was routinely employed in 193 consecutive patients with left main disease. Long-term analyses were performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events which included all-cause death, stroke, myocardial infarction, and repeat revascularization. We also analyzed the effects of variables on major adverse cardiac and cerebrovascular events at 9 years after the operation. RESULTS: The overall 9-year rates of combined outcomes (death, stroke, myocardial infarction), repeat revascularization, and major adverse cardiac and cerebrovascular events were 20.2%, 8.9%, 27.7%, respectively. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes at 9 years (hazard ratio 1.04, p = 0.033), repeat revascularization at 9 years (hazard ratio 1.11, p = 0.0030), and major adverse cardiac and cerebrovascular events at 9 years (hazard ratio 1.07, p = 0.0003). CONCLUSIONS: With our routine strategy of conventional coronary artery bypass for left main disease, patients revealed excellent long-term outcomes in terms of major adverse cardiac and cerebrovascular events. These results provide a suitable benchmark against which long-term outcomes of percutaneous coronary intervention for left main disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after coronary artery bypass for left main disease.

Non-heart transplant surgical approaches with left ventricular restoration and mitral valve operation for advanced ischaemic cardiomyopathy.

OBJECTIVES: The aim of this study was to assess long-term outcomes of non-heart transplant surgical approaches to advanced ischaemic cardiomyopathy (ICM), including left ventricular restoration (LVR) and mitral valve operation. METHODS: Since September 2002, 102 consecutive patients (mean age 65, 18 females) with advanced ICM [ejection fraction (EF) <40%, left ventricular end-systolic volume index (LVESVI) > 60 ml/m(2)] were treated using non-heart transplant procedures. A total of 84 patients with asynergy of large scar exceeding 35% of left ventricular (LV) perimeter underwent LVR, and 30 patients with greater than or equal to moderate mitral regurgitation (MR) underwent mitral valve operation such as annuloplasty (n = 23) and valve replacement (n = 7). Patients were divided into four groups according to their interagency registry for mechanically assisted circulatory support (INTERMACS) profiles: Profile 1-2 (the highest levels of clinical compromise; n = 9), Profile 3-4 (n = 40), Profile 5-6 (n = 32) and Profile ≥ 7 (n = 21). We compared the four groups, looking at survival, major adverse cardiac and cerebrovascular event (MACCE), New York Heart Association (NYHA) status, LV volume and function. RESULTS: The overall 8-year survival including 3 hospital deaths (2.9%) was 64.3% without sudden death due to arrhythmia. Ninety-nine survivors showed significant improvement in the mean NYHA status, from 2.9 to 1.4, and the mean EF (33.2-41.7%) (P < 0.0001). The mean LVESVI was significantly reduced from 104.1 to 61.4 ml/m(2) (41% volume reduction) (P < 0.0001). Seven-year survival in patients with Profiles 1-2, 3-4, 5-6 and ≥ 7 were 50.0, 57.2, 60.3 and 95.2%, respectively (P = 0.13). Freedom from MACCE at 5 years in patients with Profiles 1-2, 3-4, 5-6 and ≥ 7 were 29.6, 47.0, 67.2 and 95.2%, respectively (P = 0.0067). The improvements in NYHA status were significantly greater in patients with higher levels of clinical compromise (P < 0.0001), although, there was no significant difference in LV volume reduction and functional improvement among the four groups. Patients with Profile ≥ 7 had significantly better survival at 7 years (hazard ratio (HR): 0.11, P = 0.046) and freedom from MACCE at 5 years (HR: 0.053, P = 0.0066) compared with patients with Profiles 1-2. CONCLUSIONS: Our non-heart transplant surgical approaches using LVR and mitral valve operation for advanced ICM yielded excellent long-term outcomes in terms of survival and NYHA status, even in patients who are potential candidates for heart transplantation or LV assist devices; and are encouraging in a very particular situation where heart transplantation is limited due to organ storage.

Long-term outcomes and comparison after conventional coronary artery bypass grafting for left main disease between patients classified as percutaneous coronary intervention recommendation classes II and III.

OBJECTIVES: We retrospectively analysed long-term outcomes after conventional coronary artery bypass grafting (CABG) between patients having left main (LM) disease who should have been assigned class II and those assigned class III recommendation for percutaneous coronary intervention (PCI) according to the 2010 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines. METHODS: From January 2000 to December 2009, conventional CABG was routinely employed in 180 consecutive patients with previously untreated and stable LM lesion. A comparison between two groups (CABG for PCI class II and CABG for PCI class III) was performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, stroke [cerebral vascular accident (CVA)], myocardial infarction (MI) and repeat revascularization. We also analysed the effects of variables on MACCE at 8 years after the operation. RESULTS: The overall 8-year MACCE rates were significantly lower in the CABG for PCI class II group than in the CABG for PCI class III group (9.7% class II vs 31.1% class III; P = 0.0005). This was largely because of an increased rate of repeat revascularization (1.2% class II vs 13.8% class III; P = 0.0029). The cumulative rate of the combined outcomes of all death/CVA/MI was significantly lower in the CABG for PCI class II group (8.5% class II vs 19.2% class III; P = 0.048); there was no observed difference between the groups for all-cause death, CVA and MI. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes (Death/CVA/MI) at 8 years [odds ratio (OR) 1.05, P = 0.023], repeat revascularization at 8 years (OR 1.11, P = 0.0013) and MACCE at 8 years (OR 1.07, P < 0.0001). CONCLUSIONS: In our routine strategy of conventional CABG for LM disease, patients believed to be PCI candidates for LM disease have significantly better long-term outcomes as characterized by combined outcomes (Death/CVA/MI), repeat revascularization and MACCE. These results provide a suitable benchmark against which long-term outcomes of PCI for LM disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after CABG for LM disease.

Successful reversal of immediate paraplegia associated with repair of acute Type A aortic dissection using cerebrospinal fluid drainage.

We present a case of a 49-year old man who suffered from immediate paraplegia upon awakening from anaesthesia after surgery for acute aortic dissection Type A. A catheter was promptly inserted into the spinal canal for cerebrospinal fluid drainage, and the cerebrospinal fluid pressure was maintained <10 cmH2O. Although magnetic resonance imaging showed extensive spinal cord ischaemia, the patient gradually recovered from the paraplegia and was able to walk by himself after rehabilitation. In some cases, cerebrospinal fluid drainage can be effective for the treatment of immediate postoperative spinal cord damage.

Total arch replacement under flow monitoring during selective cerebral perfusion using a single pump.

BACKGROUND: Flow in individual vessels is passively determined when a single pump is used for selective cerebral perfusion during aortic arch surgery. We installed a Doppler flowmeter in the circuit and measured flow in the supraaortic vessels to determine flow distribution during selective cerebral perfusion. METHODS: We cannulated and perfused three supraaortic vessels using a single pump in 203 patients who underwent elective (n = 158) or emergency or urgent (n = 45) total arch replacement using a four-branched prosthetic graft. Flow rates in each branch were continuously monitored during selective cerebral perfusion. RESULTS: The respective mean flow rates in the brachiocephalic, left common carotid, and left subclavian arteries and total flow rates were 5.8, 3.3, 3.4, and 12.5 mL·kg(-1)·min(-1). The ratios of flow in these vessels to total flow were 46.5%, 26.5%, and 27.0%, respectively, and they were not affected by the total flow rate. In-hospital mortality rates among the patients who underwent elective and emergency or urgent surgery were 1.9% (n = 3) and 11.1% (n = 5), respectively, and the rates of postoperative stroke were 2.5% (n = 4) and 8.9% (n = 4), respectively. Total flow in the supraaortic vessels during selective cerebral perfusion was significantly lower in patients with neurologic complications than in those without (732 versus 806 mL/min; p = 0.034). CONCLUSIONS: Flow monitoring showed that selective perfusion using a single pump adequately distributed flow among all supraaortic vessels. This monitoring system might help to improve brain protection and outcomes during total aortic arch replacement.

Surgical treatment of an interatrial septal paraganglioma.

A 39-year-old man presented with chest pain. Chest radiography and echocardiography indicated a possible cardiac tumor. Echocardiography, computed tomography, and magnetic resonance imaging revealed a tumor in the interatrial septum. The patient underwent tumor resection under cardiopulmonary bypass. A paraganglioma was diagnosed on the basis of histopathological findings.

Long-term results and mid-term features of left ventricular reconstruction procedures on left ventricular volume, geometry, function and mitral regurgitation.

OBJECTIVES: We retrospectively analysed the long-term results and mid-term features of the surgical procedures on left ventricular (LV) volume, geometry, function and mitral regurgitation (MR) in patients with ischaemic cardiomyopathy (antero-septal dominant) who underwent LV reconstruction (LVR). METHODS: The LVR was mainly accomplished by the Dor procedure, modified by the Fontan stitch maintained by the base of the LV septum prior to the flattened-out elliptical patch closure. Other techniques such as the linear closure or septal anterior ventricular exclusion (SAVE) were used when indicated. Sixty patients were divided into three groups, undergoing LVR with the Dor procedure (n = 40), linear closure (n = 12) or SAVE (n = 8). The LV function, volume and sphericity (eccentricity index) were logged before the operation and 1 year after. RESULTS: Survivors (79% at 7 years) showed a significant improvement in the LV ejection fraction from 35.1 ± 8.1 to 43.5 ± 11.5% and NYHA status from 2.9 ± 0.7 to 1.3 ± 0.6. The LV end-systolic volume index was significantly reduced from 110.3 ± 35.9 to 57.8 ± 20.7 ml/m(2) in the Dor, from 71.9 ± 10.3 to 52.9 ± 19.4 ml/m(2) in the linear closure and from 93.1 ± 14.5 to 47.9 ± 15.7 ml/m(2) in the SAVE group. The postoperative changes in the Dor group are characterized by the reduction in the significantly larger LV volume and a more spherical chamber (systolic eccentricity index from 0.82 ± 0.10 to 0.80 ± 0.09), although not significantly so compared with other techniques. The MR grade measured on echocardiography was reduced (from 1.9 ± 0.8 to 1.7 ± 0.8), with postoperative moderate MR in four Dor patients. CONCLUSIONS: Despite the more spherical LV change, LVR led to a significant volume reduction (45%), still maintaining its physiological shape that confirmed an improved LV function and better long-term results. The Dor procedure could significantly reduce the larger LV volume without losing the end-systolic elliptical shape and mitral valvular competence like other techniques without the Fontan stitch.

Ultraviolet action spectrum for cell killing of primary porcine lens epithelial cells.

OBJECTIVES: The aim of this study was to determine ultraviolet (UV) action spectra for cell killing of primary porcine lens epithelial cells (LECs) that can be used to establish guidelines for evaluation of the hazard of cataract due to UV exposure in the workplace. METHODS: Primary porcine LECs were exposed to different doses (radiant exposure) of UV at 17 different wavelengths from 235 nm to 311 nm. At 2 days after exposure, cell viability was assessed by measuring crystal violet staining of the cells and lactate dehydrogenase release into the culture medium. The exposure dose required to kill 50% of cells (LD(50)) was determined from the dose-effect relationship obtained at each wavelength and was used to construct action spectra. RESULTS: The action spectra had a broad minimum in the approximate range of 250-280 nm, indicating that UV is most hazardous to porcine LECs within this wavelength range. The spectra rose steeply at both longer and shorter wavelengths. These action spectra are consistent with the in vivo action spectra for opacities in the rabbit lens and for light scattering in the rat lens, taking the transmittance of the ocular media into account. CONCLUSIONS: These results will help to determine a UV hazard function for cataract formation, which can be used to draft guidelines for evaluation of the hazard of cataract due to UV exposure in the workplace.

Brain swelling in acute superior vena cava syndrome due to aortic dissection: unusual and lethal manifestation aggravated by induction of general anesthesia.

A 32-year-old woman with Marfan syndrome experienced acute superior vena cava syndrome due to aortic dissection. The patient had previously undergone a Bentall operation. The aneurysm from the ascending to the transverse aorta compressed the superior vena cava, the right pulmonary artery, and the trachea. The rare and life-threatening neurological complication in this patient may have been related to brain edema, which was revealed by preoperative computed tomography. The induction of general anesthesia aggravated the symptoms of the superior vena cava syndrome and led to a fatal condition. Additional cannulation in the right subclavian vein was mandatory to alleviate the symptoms because the venous drainage from the upper half of the body created only by the femorofemoral bypass was not adequate. Total arch replacement was performed. The postoperative course was uneventful.

Can early aortic root surgery prevent further aortic dissection in Marfan syndrome?

We reviewed 50 patients with Marfan syndrome who underwent surgery for aortic root pathologies comprising a root aneurysm without (n = 25; group A) and with (n = 25; group B) dissection. Aortic root repair included Bentall (n = 37) and valve-sparing (n = 13) procedures. Hospital mortality was 4.0%. Twenty-two patients required 36 repeat surgeries on the distal aorta. The main indication for re-intervention was the dilation of the false lumen. In group A, the distal aorta was stable for up to 7 years, but new dissection developed in 5 (33.3%) of the 15 patients who were followed up for >7 years after the root repair. Actuarial survival including operative mortality was 88.1 and 65.0% at 10 and 20 years, respectively; groups A and B did not significantly differ. Rates of freedom from all-cause death, new dissection or repeated aortic surgery were 60.1, 44.5 and 26.0% at 5, 10 and 15 years, respectively. Group A was significantly better than group B. Prophylactic aortic root repair apparently reduces the likelihood of overall adverse events, but it cannot guarantee the prevention of further aortic dissection. A multidisciplinary approach is needed for patients with Marfan syndrome.

[Long-term results and analysis of multiple surgical approaches for ischemic cardiomyopathy with left ventricular reconstruction, including scarred endocardiectomy for arrhythmia therapy, and mitral valve surgery].

Among 73 patients with ischemic cardiomyopathy [ejection fraction (EF) < 40%, left ventricular end systolic volume index (LVESVI) > 60 ml/m2], 65 patients with large scar underwent left ventricular reconstruction (LVR) including scarred endocardiectomy against arrhythmia and 13 with 3 + mitral regurgitation (MR) mitral valve surgery [mitral annular plasty (MAP): n = 9, mitral valve replacement (MVR): n = 4]. Eight-year survival including 1 perioperative death (1.4%) was 773% without death due to arrhythmia. 69 survivors revealed significant improvement in New York Heart Association (NYHA) class, and lefe ventricular (LV) function in pulmonary artery pressure (PAP) and EF. LV volume significantly reduced from 103.6 to 57.5 ml/m2 in LVESVI (44% volume reduction) [p < 0.0001]. Postoperative LV shape became significantly spherical [eccentricity index (EI) closer to 0], however, MR grade was significantly reduced from 2.0 to 1.6 (p < 0.0003). Freedom from all deaths including hospitalization for cardiac causes was 71.1% at 8 years. One patient required implantable cardioverter defibrillator (ICD) for spontaneous ventricular tachycardia (VT). Multivariate Cox's regression model showed that preoperative large left ventricular end diastolic volume index (LVEDVI) [hazard ratio (HR) 1.02], postoperative large LVESVI (HR 1.03) and preoperative high NYHA class (HR 3.05) were significant risk factors affecting all deaths including hospitalization for cardiac causes. Of 24 patients with 2.5 + MR, mitral valve surgery (MAP, MVR or MAP + LVR) demonstrated significant improvement of MR (3.6 to 1.3 in MAP/MVR and 3.5 to 1.0 in MAP + LVR) compared with isolated LVR (2.6 to 2.2), although, there was no significant change in LV volume reduction. Our surgical approach to ischemic cardiomyopathy revealed excellent long-term results without death due to arrhythmia. Risk factor analysis recommended earlier and more aggressive surgical approach to achieve both LV volume reduction, MR and arrhythmia control.

[Long term clinical outcomes of Baerveldt glaucoma implantation via the pars plana].

PURPOSE: To present the long-term follow-up results of Baerveldt glaucoma implant (BGI) with a drainage tube from the pars plana in secondary glaucoma patients. METHODS: The subjects were patients with light perception and secondary glaucoma (> 21 mmHg) who had received more than 2 glaucoma operations: 11 were neovascular glaucoma patients and 5 angle-closure glaucoma patients with peripheral anterior synechia. After vitreous surgery, a BGI plate was fixed at the sclera in the superior temporal equator, and a drainage tube inserted from the pars plana into the vitreous cavity. The successful criteria needed to satisfy the 3 following conditions: 1) vision of more than light perception, 2) IOP > or = 5 mmHg and not higher than 22 mmHg, 3) no need for further glaucoma operations. RESULTS: The follow-up period was 82.5 months (from 5 to 172 months). Eight patients were judged a success, 4 patients a failure and 4 patients quit for personal reasons. The 10-year success rate was estimated at 72.8%. CONCLUSIONS: BGI via the pars plana is a useful method for long term IOP lowering effect in secondary glaucoma.