Rod-like intramitochondrial inclusions after hypothermic chemical cardioplegia during cardiac operations.

Rod-like intramitochondrial inclusions in the myocardial cells were observed after hypothermic chemical cardioplegia in three out of 20 patients who underwent coronary bypass operations. They were not seen in another group of 20 patients who underwent an aortic valve replacement operation in whom only topical cooling was used for myocardial protection. The occurrence of rod-like intramitochondrial inclusions could not be correlated with other signs of ischemic myocardial injury. X-ray microanalysis did not reveal any inorganic substance in the intramitochondrial inclusions. Therefore, we believe that their occurrence was not related to the calcium paradox phenomenon, a feared complication of cardiac operations.

Life-threatening complications of cardiac operations and occurrence of myocardial catecholamine bombs.

Myocardial catecholamine bombs (huge local intra-axonal accumulations of catecholamine, mainly norepinephrine, within cardiac tissue) were observed in (right auricular) myocardial biopsy specimens in 16 of 65 adult patients selected randomly from a series of elective cardiac operations. The occurrence of catecholamine bombs was in highly significant correlation (p less than 0.001) with the occurrence of life-threatening complications of cardiac operations (life-threatening arrhythmias [ventricular tachycardias, ventricular fibrillation, asystole], clinically evident perioperative myocardial infarction/postoperative low-output syndrome, death). There was a very close correlation between the occurrence of catecholamine bombs and life-threatening arrhythmias. Life-threatening arrhythmias occurred in 13 patients. Eight of them belonged to the group of 16 patients with catecholamine bombs and five belonged to the group of 49 patients with no bombs; the difference (8/16 versus 5/49) is very clear (p less than 0.001). It was our experience that dangerous arrhythmias related to catecholamine bombs may occur as late as during the second postoperative week. We believe our observations are of considerable clinical importance, because catecholamine bombs are easily identified by fluorescence microscopic examination of right auricular myocardial specimens retrieved intraoperatively, and patients at high risk can then be selected (during the operation) for more extensive and prolonged surveillance and possibly prophylactic treatment.

Value of high-resolution computed tomography in routine evaluation of lung transplantation recipients during development of bronchiolitis obliterans syndrome.

BACKGROUND: Chronic rejection is a major long-term complication after lung transplantation. The purpose of our study was to evaluate the role of repeated high-resolution computed tomographic examinations in monitoring the development of bronchiolitis obliterans syndrome after lung transplantation. METHODS: A total of 126 high-resolution computed tomographic examination in 13 lung transplant recipients was analyzed. During a mean follow-up period of 23 months, bronchiolitis obliterans syndrome developed in eight of the patients. A scoring system from 0 to 10 based on the number of chronic changes on high-resolution computed tomography was developed, and the score of each patient was compared with decline in the forced expiratory volume in 1 second and maximal forced expiratory flow rate of 50% of the forced vital capacity. RESULTS: The score of chronic changes, measured at 1 year after transplantation, correlated inversely with the values of forced expiratory volume in 1 second and maximal forced expiratory flow rate at 50% of the forced vital capacity (p < 0.05). Stage I bronchiolitis obliterans syndrome was associated with scores of 4 to 6 (mean 5.0), stage 2 with scores of 6 to 9 (mean 7.0), and stage 3 with scores of 6 to 9 (mean 7.7). The sensitivity of high-resolution computed tomography was 93% and its specificity was 92% when five chronic changes were used as a cutoff level. CONCLUSIONS: The progress of chronic changes on high-resolution computed tomography occurs concurrently with the development of bronchiolitis obliterans syndrome. High-resolution computed tomography may provide additional morphologic information for noninvasive evaluation of chronic lung rejection.

Comparative formaldehyde-induced and glyoxylic acid-induced fluorescence histochemical studies on the intrinsic adrenergic innervation of the intestine and the liver of normal and vagotomized cats.

The inbuilt intrinsic adrenergic nervous apparatus of the intestine and liver of the cat was studied using 1. the formaldehyde-induced fluorescence histochemical method and 2. the glyoxylic acid-induced fluorescence histochemical method for serial microtome sections and whole mount tissue layers or smear preparations. In addition, the effect of I) total abdominal infra-diaphragmatic vagotomy with or without associated Finney-type gastro-duodenostomy and II) unilateral (left or right) and bilateral cervical vagotomy with or without tracheostomy on the intrinsic adrenergic innervation was tested. Fluorescing varicose axons, both "free" (i.e. unrelated to the blood vessels) and gathered to typical perivascular nerve plexuses were observed in all segments and all layers of the wall of the intestine. The density of the adrenergic innervation varied remarkably from an area to another, even in the same segment and tissue layer, which makes comparative estimations of the density of the innervation very difficult. However, the intrinsic adrenergic innervation of the circular muscle layer of the colon and the rectum seems to be consistently quite rich, and in the rectum, also the longitudinal muscle layer is relatively heavily innervated. It thus seems obvious that (in the cat) also the direct adrenergic innervation of the external smooth muscle layers is of considerable importance, specially in the rectum. In contrast, the results of the present study clearly indicate that the liver parenchyma (of the cat) is devoid of functional intrinsic adrenergic innervation. Vagotomies did not cause any changes in the intrinsic adrenergic innervation of the intestine and liver: even after complete vagotomy no reduction was observed in the number of fluorescing axons or in the intensity of the fluorescence. Consequently, the vagal contribution of adrenergic axons to the liver and the intestine must be negligible, at least in the cat. The use of the glyoxylic acid-induced fluorescence histochemical method and whole-mount tissue layers was found most suitable for mapping and comparative estimation of the density of the intrinsic adrenergic nerve net, and is therefore recommended for other similar or related studies.

Multi-score estimation of catecholamine fluorescence for clinical purposes.

Experience accumulated at multi-score semiquantitation of catecholamine fluorescence of glyoxylic acid-treated stretch preparations of human clinical specimens is presented. The methodology and criteria of quantitation are described in detail. For an example, comparison between 3 different methods for analyzing neural-bound noradrenaline in human myocardial tissue in various heart diseases (obtained during the course of cardiac surgery) is presented: Biochemical determination of tissue noradrenaline content multi-score estimation of catecholamine fluorescence of glyoxylic acid-treated stretch preparations microfluorimetric analysis of the same stretch preparations. The results show that the multi-score estimation method gives a reliable concept of the relative amounts of noradrenaline stored in the intrinsic adrenergic nerve net (corresponding closely to the individual and group differences observed at biochemical noradrenaline determination). In addition, possible regional differences, alterations in the structural integrity of the inbuilt intrinsic nerve net, and other structural changes (e.g. pathological catecholamine accumulations) are easily recognized, whereas biochemical estimation cannot give information on structural aspects, which may have important clinical repercussions. Microfluorimetry does not seem suitable for studies on human myocardial specimens for several reasons which are discussed. The method of multi-score estimation of catecholamine fluorescence described and discussed is recommended for other similar and related studies on human clinical materials.

Reinnervation of human skin grafts: a histochemical study.

The reinnervation of nine human skin grafts was investigated using histochemical thiocholine methods for the demonstration of cholinesterases. The regenerated cutaneous nerves showed both specific acetylcholinesterase and nonspecific cholinesterase reactions. In the youngest specimens, taken 3 weeks after the grafting, such regenerated nerves were seen both at the subdermal level under the graft and at the margins of the graft. These nerves seemed to orient toward the denervated graft area. The growing nerves were generally distributed in a random fashion. The reinnervation of some hair follicles, erector pili muscles, and sweat glands were observed in well-innervated full-thickness and thick partial-thickness skin grafts. It is suggested that this target-organ control of regenerating nerves occurs as a result of the action of chemotactic factors. A well-innervated graft bed seems to be important for optimum reinnervation of skin grafts. Fibrosis and scarring seem to hamper nerve regeneration.

Abdominal aortic aneurysm and dissection after blunt trauma.

A case of abdominal aortic aneurysm and dissection after blunt trauma is presented. Unlike traumatic lesions of the thoracic aorta, this condition seems to be extremely rare, and may therefore deserve publication. Conservative surgery (resection of the dissected intimal flaps, closure of the aortotomy with a Blalock-type vascular suture) gave good early and late (6 years follow-up) results.

Early and late results of surgery for atrial septal defect in patients aged over 60 years.

To assess the risks and benefits attending the surgical repair of atrial septal defect in the elderly the case histories of all patients operated on at the age of 60 years or more were reviewed and follow-up study, including cardiac catheterization, was performed. A total of 17 patients (12 females and 5 males) were identified. The left-to-right shunt ratio averaged 2.7. Fifteen patients had abnormally high systolic (greater than 30 mmHg) or mean (greater than 20 mmHg) pulmonary artery pressure and the pulmonary arterial resistance was elevated (greater than 1.5 units) in eight. One patient died shortly after surgery (operative mortality, 6%) and major postoperative complications were found in four additional patients (24%). Three months after surgery the effort capacity had improved by at least one class in all survivors. After an average of 8.2 years follow-up 12 patients were alive. Ten of them felt better than preoperatively. Eight agreed to cardiac catheterization. The pulmonary blood flow was markedly decreased in all (means, 5.6 l/min postoperatively, vs 11.2 l/min preoperatively) even though a hemodynamically significant shunt persisted in two patients. The mean pulmonary artery pressure had decreased in all who were hypertensive before operation (mean, 25 mmHg vs 33 mmHg). It had slightly increased in patients who had normal pulmonary pressure preoperatively (mean, 27 mmHg vs 19 mmHg). The pulmonary arterial resistance was higher than before surgery in all except one patient (mean, 2.2 units vs 1.5 units).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of addition of magnesium to potassium-containing fluorocarbon cardioplegic preparations. An experimental study.

The effect of magnesium on potassium fluorocarbon cardioplegia was studied in 20 rabbits. Isolated hearts with ascending aortas were perfused with oxygenated and cooled (+4 degrees C) fluorocarbon solutions. In 10 experiments, the solution contained 20 mmol/l of potassium, in 10 further experiments, 20 mmol/l of potassium and 15 mmol/l of magnesium. Ultrastructural preservation of the myocardium was studied using transmission electron microscopy. In addition, the cation contents of the myocardium were studied by flame atomic absorption spectrophotometry (calcium, magnesium) or electrothermal atomic absorption spectrophotometry (copper). After 120 minutes of ischaemia, areas of moderate or severe ultrastructural myocardial cell damage were observed in both groups but severe damage was more extensive and commoner in the group with no access to magnesium. Preservation of the capillary endothelium was also worse in that group. There was a highly significant increase in magnesium content, a decrease in calcium content and an increase in the magnesium/calcium ratio following magnesium-potassium fluorocarbon infusion. The copper content remained unchanged. A protective effect of magnesium was observed. The electrolyte content of cardioplegic solutions also alters the electrolyte content of the myocardium. This may be important in reperfusion.

Adrenergic innervation of aortic patch-grafts in rats.

The regeneration of vascular adrenergic nerves was studied using the glyoxylic acid-induced fluorescence method for the specific demonstration of adrenergic nerves in syngeneic patch-grafts of the right atrium of the heart, vena cava and glutaraldehyde-treated vena cava transplanted into the abdominal aorta of the rat. Glutaraldehyde-treated segments of the supradiaphragmatic inferior vena cava were transplanted into the abdominal aorta of rats as well. At the end of the observation period of 24 weeks limited, patchy and defective innervation was observed in the syngeneic vena cava and atrial patches. No adrenergic nerves were found in the glutaraldehyde-treated vein patch-grafts or vein grafts. Owing to the very poor innervation of atrial and venous patch-grafts the results are not entirely in agreement with the target organ concept of adrenergic nerve regeneration. In this study the suture line around the patch graft probably hampers regeneration of vascular adrenergic nerves in the patches.