Hashimoto's encephalopathy presenting with micrographia as a typical feature of parkinsonism.

We describe here a 63-year-old woman who presented with gait disturbance and micrographia. Laboratory tests demonstrated the presence of anti-thyroperoxidase (TPO) antibodies and vitamin B(12) deficiency accompanied by the presence of anti-parietal cell antibodies. Lymphocytosis with increased protein was detected in cerebral spinal fluid (CSF). Serum autoantibodies against the anti-NH(2) terminal of α-enolase (NAE), a specific diagnostic marker for Hashimoto's encephalopathy (HE), were also detected. Since underlying autoimmune conditions were suspected to be associated with Hashimoto's disease, steroid therapy was conducted, and the neurological symptoms improved a few days after the therapy was started. Attention should be given to the possibility that typical parkinsonism showing micrographia is caused by HE.

Evaluation of combined therapy with chemoembolization and ethanol injection for advanced hepatocellular carcinoma.

To evaluate the therapeutic efficacy of transcatheter arterial chemoembolization (TACE) combined with percutaneous ethanol injection therapy (PEIT) for advanced hepatocellular carcinoma, we studied the effectiveness of TACE therapy combined with PEIT (50 cases) and TACE alone (50 cases). In both groups, patients had multiple lesions, or a single lesion with a diameter exceeding 2 cm or with vascular invasion (stages II, III, and IV in the tumor staging classification of the Liver Cancer Study Group of Japan). The clinical features in the two groups were comparable. The cumulative survival rates with TACE-PEIT were 95.0% for 1 year, 72.5% for 2 years, and 50.0% for 3 years, whereas the rates with TACE alone were 92.5% for 1 year, 57.5% for 2 years, and 20.0% for 3 years. The survival rate in the TACE-PEIT group was significantly higher than that in the TACE alone group. Moreover, the survival rate of patients with stage II or III disease in the TACE-PEIT group was significantly better than that in the TACE alone group, and the survival rate of patients with Child's classification B or C in the TACE-PEIT group was significantly higher than that in the TACE alone group. Multivariate analysis using Cox's proportional hazard regression model showed that the most significant prognostic factors in the TACE-PEIT group were tumor embolus in the portal vein and the number of tumors. These results suggest the effectiveness of combining TACE and PEIT for the treatment of advanced hepatocellular carcinoma.

Function of expanded-polytetrafluoroethylene laminated trileaflet valves in animals.

A stent-mounted trileaflet cardiac valve prosthesis has been developed in which the valve leaflets were fabricated from 0.003-mm films of expanded polytetrafluoroethylene laminated in 4 to 15 layers. A total of 28 valves of varying leaflet thickness were implanted in the tricuspid position in dogs. Cardiac catheterization performed during the follow-up period between 1 week and 15 months after valve replacement in 20 surviving animals showed that the initial good function was maintained in 12 dogs for up to 15 months, whereas valve dysfunction developed in 8 other dogs within 6 months. Autopsy revealed that the cause of valve dysfunction among the eight dogs was cusp stiffening with or without retraction in six, dehiscence of the suture ring in one, and strut entrapment in one. This study demonstrated that the thickness of the leaflet material is an important factor affecting the long-term function in vivo.

Conduit repairs of transposition complexes. A report of 14 cases.

Of 14 patients with transposition complexes undergoing conduit repairs, 10 had complete transposition of the great arteries (TGA) and 4 double-outlet right ventricle. All 14 had ventricular septal defect (VSD). Ten had pulmonary stenosis, one had an atrial septal defect, and one had patent ductus arteriosus. The ages of the patients ranged from 13 months to 18 years. Six patients were treated with nine palliative operations: four systemic-pulmonary artery shunts, three atrioseptectomies, and two pulmonary banding procedures. Four patients died immediately after the operation. Among the 10 operative survivors, there were no late deaths during the follow-up periods from 5 months through 6 years. Review of the factors influencine the early operative results has stressed the importance of correct timing of operation with or without palliative treatment, increased surgical experience, and the critical evaluation of intracardiac anatomy.

Open-position fixation of bioprostheses for more physiological performance. Fluoroscopic observations of leaflet movements in vivo.

A new model of the stent-mounted porcine aortic bioprosthesis was prepared with 0.625% glutaraldehyde while the valve was partially open. A radiopaque marker was attached to the center of the free margin of each leaflet so that the leaflet movements could be observed in an in vivo testing unit by fluoroscopic cinematography. This valve was compared with a porcine xenograft that currently is available commercially. While the heart was beating, the specially prepared leaflets showed some characteristics that contrasted with those of the currently used bioprosthesis. These features included (1) uniformity versus asymmetry of leaflet excursions under low flow conditions, (2) slower and more gradual closing (actual closing time averaging 536 msec versus 81 msec), and (3) more prolonged period of valve opening, the duration of opening averaging 60% versus 49% of the cardiac cycle. These features support the validity of open-position fixation as a means of further improving xenograft durability.

Pulmonary flow-resistance relationships in allografts after single lung transplantation in dogs.

To evaluate the applicability of single lung transplantation as a treatment of pulmonary hypertension, we investigated the relationships between the pulmonary blood flow and resistance in allografts 10 days after single lung transplantation in dogs. In eight surviving recipients and five healthy dogs (control group), pulmonary flow-resistance relationships were investigated at flows in the range of 0.3 to 2.0 L/min at 0.1 L/min increments. Resistance decreased from 2585 to 746 dyne.sec.cm-5 in the successful group (five allografts receiving complete studies) and 2400 to 891 in the control group with an increase of flow. Lung water content of the successful group was 2.0 times that of the control group (successful group, 95.6 +/- 16.7 gm; control group, 47.8 +/- 7.5 gm), and water content of the other allografts (unsuccessful group), including allografts of dogs that died before investigations, was 2.2 times that of the successful group (unsuccessful group, 211.0 +/- 89.6 gm). The chest roentgenograms of the successful group showed mild or moderate consolidations, whereas those of the unsuccessful group showed severe consolidations, but no difference was found in pulmonary flow-resistance relationships between the successful and the control groups. These results show that the allografts, which have about twice the water content of normal lung, maintain adequate pulmonary vascular function. We concluded that single lung transplantation could be an effective treatment for pulmonary hypertension.

A comparative analysis of left ventriculography and root aortography for estimating aortic annular size.

This study was undertaken to compare the usefulness of left ventriculography versus root aortography as a means of assessing the aortic annular size in 75 patients with a narrow aortic anulus. These patients were divided into two groups: Group I consisted of 57 patients undergoing standard aortic valve replacement with a 21 mm prosthesis and Group II consisted of 18 patients undergoing modified aortic valve replacement with the aid of an anulus-enlarging procedure or an apico-aortic conduit. In Group I, left ventriculography gave 23.2 +/- 1.8 mm (mean +/- standard deviation), whereas the aortography method showed 22.4 +/- 2.7 mm (p less than 0.05). Those values of 20 mm or less were regarded as imperfect measurements; inaccurate results were more frequent in the aortography method (16 cases; 28%) than in the left ventriculography method (only two cases; 3.5%), with significant difference (p less than 0.025%). In Group II, there was no significant difference in respective values determined by the two different methods; 18.7 +/- 3.0 mm, with a range from 13 to 23 mm in the left ventriculography method, and 19.9 +/- 3.1 mm, with a range from 14 to 24 mm, in the aortography method (p greater than 0.2). Imperfect measurement by the aortography method tended to occur when the cusp base was severely deformed. The results indicated that left ventriculography was more reliable than root aortography for estimating the size of the aortic anulus.

Open versus closed position fixation of bioprosthesis. Comparative in vitro studies from the viewpoint of durability.

In an effort to normalize the dynamic leaflet behavior of a porcine bioprosthesis, an experimental attempt was made to treat a tissue heart valve with 0.625% glutaraldehyde in the open position ("open-type valve"). Eighteen open-type valves, having fixed openings of various sizes, were examined with our pulse simulators. Eight closed-type valves, which were treated in the closed position, were studied for comparison. The results showed that closed-type valve tended to offer an immobile cusp at a low flow state; at a pump pressure of 90 mm Hg in a pulsatile flow or under steady flows of no more than 10 L/min. By contrast, the open-type valve showed the symmetric cusps opening with circular orifices at any given flow rates. Analysis of the pressure loss coefficient revealed that the leaflets prepared in the open position produced only a minimal impediment to the forward flow. One half of the anatomic orifice of a valve was considered to be the optimal size for the fixed opening. It is concluded that open position fixation is expected to provide the bioprosthesis with improved fatigue durability in patients with low cardiac output syndrome and in small children.

An improved de Vega tricuspid annuloplasty.

Constricting the tricuspid annulus to an optimal size and ensuring competency of the suture in situ are essential to the performance of a successful de Vega annuloplasty. An approach to this goal is presented. Important maneuvers include placement of the inside suture just on the ring portion, use of a 33 mm of 35 mm valve obturator to obtain an annulus of the desired size, and ligation of the knots at their roots to prevent potential loosening.

Sutureless aortic valve replacement for periannular abscess due to active bacterial endocarditis: a new translocation technique.

A composite valve prosthesis was prepared by direct suture of the ring prosthesis, which was separated from an intraluminal ringed graft, with a St. Jude Medical aortic valve. A new translocation method using this composite valve prosthesis was performed on a patient with aortic periannular abscess, with favorable result.

Stent creep of porcine bioprosthesis in the mitral position.

Stent creep, often associated with valve malfunction, is said to play an important role in the long-term performance of a porcine bioprosthesis. We have measured the angle of the stent post showing maximal inward bending (IBA) on 44 mitral porcine bioprostheses. All of them were explanted 1 to 12 years (mean explant time, 7.8 years) postoperatively at reoperation. Patients included 19 men and 25 women, ranging in age from 24 to 66 years (mean age, 47.2 years). Mean IBA was 12.7 +/- 4.2 [SD] degrees in 14 valves implanted for 7 years or less and 16.4 +/- 5.8 degrees in 30 valves implanted 8 years or longer (p less than 0.05). There was no significant difference in IBA among valves based on type (25 Hancock valves, 15.0 +/- 4.7 degrees; 10 Angell-Shiley valves, 16.2 +/- 8.6 degrees; and 9 Carpentier-Edwards valves, 14.4 +/- 3.7 degrees). There was a significant difference in IBA based on valve size (37 valves measuring 25-29 mm in diameter, 16.3 +/- 5.1 degrees; and 7 valves measuring 31 mm in diameter, 9.9 +/- 5.1 degrees; p less than 0.05). IBA showed a tendency to have a large value in a heart with a small left ventricular end-systolic volume. We conclude that (1) stent creep is not related to the materials or designs of the stent post, but tends to increase with passage of time in place; and (2) compression of the left ventricular wall is one of the main causes of stent-post bending.

In vitro analysis of performance of porcine xenografts with inward bending of stent posts: real-time measurement of valve orifice area using an area meter.

The influence of inward bending of the stent posts on bioprosthetic valve function was assessed in a hydromechanical simulation of the left heart. A Carpentier-Edwards mitral xenograft (31 mm) and an aortic xenograft (27 mm) were used. Valve function was evaluated before and after the stent posts were bent inward 15 degrees by suture constriction of the tops of the three posts. To evaluate the effects of the stent-post deformity on valve performance, the mean transvalvular pressure drop during steady flow, the bioprosthetic valve orifice area, and the maximum valve opening and closing speeds during pulsatile flow were measured using an area meter. Steady-flow data showed identical transvalvular pressure drops, and no significant difference in valve performance was detected in the pulsatile-flow study under the two experimental conditions (i.e., normal valve and deformed valve). We conclude that a 15-degree inward bending of the stent posts does not appreciably affect valve function in vitro.

A new method of conduction system staining.

Visualization of the conduction bundle is advantageous in the prevention of surgical trauma to the conduction system during open-heart surgery. Because vital staining using an iodine starch complex has been known to result in tissue damage, we have evaluated the effects of iodine gas on the specialized conduction system. The conduction bundle was stained, well enough to be identified, with iodine tincture, with Lugol's solution, and with iodine gas. However, all these agents except for iodine gas caused marked electrophysiological changes. Similar changes occurred with the use of ethanol and of 10% potassium iodine solution, which are the solvents of iodine tincture and Lugol's solution, respectively. Microscopic examination showed that iodine tincture, Lugol's solution, and their solvents caused marked histological changes in the conduction tissue. However, no significant changes in the conduction tissue were noted from iodine gas spraying. Therefore, tissue damage caused by iodine tincture and Lugol's solution was thought to be due not to a reaction to the iodine starch complex itself, but to their solvents. In a long-term experimental study of 10 dogs, we found that iodine gas caused no electrophysiological disturbances or damage of microscopic tissue. Of the agents we tested, only iodine gas is free from harmful effects and can be used clinically.

Endoscopic follow-up study of development of gastric antral vascular ectasia associated with liver cirrhosis.

Gastric antral vascular ectasia is an important cause of chronic gastrointestinal blood loss. However, its development and progression have not yet been clarified. We investigated its early lesions and progression by reviewing endoscopic films of five patients with gastric antral vascular ectasia followed for liver cirrhosis. In all patients, early findings were prepyloric red spots. In two patients, anemia due to gastrointestinal bleeding was already observed when vascular lesions were confined to the distal antrum. In the other three patients, anemia was observed 1-2 years after they showed a diagnostic pattern of gastric antral vascular ectasia. The vascular lesions gradually thickened and extended throughout the antrum, with the complete picture shown in 1.5-5 years. The pattern of distribution was classified into three types: diffuse spotty, diffuse confluent, and striped. These types could be predicted before the complete formation. Gastric antral vascular ectasia associated with liver cirrhosis started as prepyloric red spots and extended to the proximal antrum in various ways and varying time courses of less than 5 years; this entity may cause hemorrhage even in the early stage.

Cell-mediated and humoral immune response to non-viable Mycoplasma pulmonis in mice enhanced by cross-linked ricin.

The enhancing effect of cross-linked ricin (CL-ricin) on the cell-mediated and humoral immune response of mice to non-viable Mycoplasma pulmonis was studied. The cell-mediated immune response was evaluated by means of the delayed-type footpad swelling, and the humoral immune response by means of the indirect hemagglutination test. Mice pre-treated subcutaneously with non-viable M. pulmonis and CL-ricin showed significantly increased delayed-type footpad swelling when they were injected in the footpad with the same antigen 7 days later. Delayed-type footpad swelling was not detected in mice pre-treated only with non-viable M. pulmonis or CL-ricin followed by footpad injection with non-viable M. pulmonis. Injection of non-viable M. pulmonis in the footpad on Days 3, 7, 14, 21, 28, 35 and 42 after pre-treatment with non-viable M. pulmonis and CL-ricin resulted in significant footpad swelling. Delayed-type footpad swelling was transferred by intravenous injection of spleen cells from mice which had been pre-treated 7 days previously with non-viable M. pulmonis and CL-ricin into non-treated recipient mice. Intravenous injection of anti-mouse thymus cell serum into mice previously pre-treated with non-viable M. pulmonis and CL-ricin reduced the delayed-type footpad swelling significantly. Mice pre-treated subcutaneously with non-viable M. pulmonis and CL-ricin showed a marked increase in serum antibody titers compared with those that received non-viable M. pulmonis alone.

Open aortic bioprosthesis at zero pressure. A new concept in glutaraldehyde fixation of tissue valve.

An experimental trial has been made to fix a porcine aortic valve in a semi-open position using 1 percent glutaraldehyde (open model). Four valves of open model xenograft were examined with use of our pulse-simulator. Four valves fixed in the closed position (closed model) and one untreated valve were studied for comparison. Comparison of the opening characteristics at the pump pressure of 120 gr/sq.cm revealed the significant difference in that the open model valves gave the simultaneous cusp opening with a circular orifice, while the closed model valves opened in sequence with irregular orifice. This relationship was substantiated by forward flow measurement. Analysis of the flow velocity curve confirmed the competence of the open model xenograft. These results suggest that the open aortic bioprosthesis may provide an improved hemodynamic function under low flow conditions.

A comparative study between glutaraldehyde-preserved aortic and pulmonary heterograft valves in the tricuspid position in dogs.

Morphological observations have been presented on 10 metaperiodate-glutaraldehyde-preserved aortic heterograft valves and 5 pulmonary heterograft valves implanted into the tricuspid position for periods ranging from 7 to 183 days. It is recognized that there was a relatively minimal histological change in pulmonary valves. However, calcification of implanted aortic cusps was observed in 20% (2 out of 10) of cases and high incidence of thrombus formation on aortic cusps was recognized, although there were none on pulmonary cusps. It seems reasonable to presume that the high incidence of thrombus formation on the aortic valves is primarily due to the decreased pliability and stiffness of the cusps. It is concluded that the pulmonary valves rather than the aortic valves are recommended for tricuspid valve replacement.

A new preshaped catheter for right ventriculography with minimal artificial tricuspid regurgitation.

A new type of preshaped angiographic catheter for right ventriculography to be inserted from the femoral vein has been developed. Right ventriculography using this catheter was conducted in about five hundred clinical cases. The result has revealed that this catheter is very useful in clinical settings without causing catheter-induced tricuspid regurgitation (TR) allowing easier and safer right ventriculography as compared with conventional catheters.

[Clinical study on the effects of assist bypass on left ventricular contractility].

This study was undertaken to evaluate the effects of circulatory support on cardiac function in 7 patients. They were 2 men and 5 women with of age 34-54 years; Six patients underwent mitral valve replacement and one had mitral valve plasty. End-systolic pressure/volume (ESP/ESV) representing left ventricular contractility was measured just before ECC starting and after cardiac beating began in the process of rewarming. Measurements were repeated at every, interval of 10 minutes up to 60 minutes. ESP/ESV (mmHg/ml) [% of that before ECC] were as following; before ECC: 1.69 +/- 0.68 (mean +/- SD) [100], after 10 minutes; 0.40 +/- 0.24 [25.1 +/- 13.8], after 20 minutes; 0.52 +/- 0.26 [31.5 +/- 12.9], after 30 minutes; 0.77 +/- 0.28 [47.6 +/- 10.5], after 40 minutes; 0.97 +/- 0.26 [60.5 +/- 11.3], after 50 minutes; 1.18 +/- 0.46 [70.6]8.0], after 60 minutes; 1.36 +/- 0.56[80.4 +/- 12.7]. It took 39.6 minutes to recover up to 69% of that before ECC. These data suggested that the myocardial ischemia associated with aortic cross clamping continued for at least 60 minutes after cardiac beating resumed. We concluded that assist bypass should be applied to those who could not be weaned from ECC despite adequate use of catecholamine and volume loading.

[Limitations and extension of surgical indications for acquired valvular heart disease; retrospective study of hospital death].

Between 1981 and 1987, valvular surgery was performed in 988 patients, 27 of which were dead before discharge. Among them, 14 patients of cardiac deaths due to low cardiac output syndrome (LOS) and arrhythmias were analyzed to withdraw factors correlated with their cause of death. There was a tendency for the patients with stenotic valvular disease to die of LOS and regurgitant valvular lesions of arrhythmias. Statistical analysis showed the cause of deaths were multifarious including pulmonary, hepatic and renal failure, so no definite factor was pointed out. Case study of typical limited and extended surgical indications revealed (1) the patients with mitral stenosis combined with organic tricuspid regurgitation and RV/LV EDVI ratio over 1.5, and (2) the patients with aortic insufficiency and LVEDVI over 400 ml/m2 or LVESVI over 300 ml/m2 were candidate for hospital death after valve replacement. Extended approach for those patients should be two staged heart transplantation using ventricular assist device.