Different pathological findings in each of four parathyroid glands in a long-standing hemodialysis patient.

A 51-year-old male patient with chronic renal failure, who had required dialysis for 22 years, presented with a cervical mass. Laboratory data were consistent with secondary hyperparathyroidism due to chronic renal failure. Cervical exploration was performed with excision of four parathyroid glands and autotransplantation of the normal gland into the forearm. The cervical tumor of the right inferior gland demonstrated parathyroid carcinoma histologically. Adenoma of the right superior gland and hyperplasia of the left superior gland were also recognized. The left inferior gland was normal. A few cases of parathyroid carcinoma in patients on maintenance hemodialysis have been previously reported. However, this is the first report in which all four parathyroid glands revealed different pathological findings: carcinoma, adenoma, hyperplasia and normal gland. Chronic stimulation of the parathyroid glands to release parathyroid hormone might have caused the variety of findings in the four parathyroid glands.

[Autonomic imbalance and renal dysfunction cause loss of nocturnal decrease in blood pressure in diabetic nephropathy].

Many diabetic patients with nephropathy show loss of the nocturnal decrease in blood pressure. However, the mechanism is not yet fully understood. Twenty-four-hour blood pressure in type II diabetic patients was evaluated by ambulatory blood pressure monitoring(with TM2425 A and D Co. Tokyo). The power spectrum of blood pressure was also analyzed as an index of autonomic cardiovascular modulation using the same device. The ratio of lower frequency(LF) to higher frequency(HF) of heart rate rhythmic oscillations was determined as an index of sympathovagal balance. Patients were divided into two subgroups (Diabetes mellitus group, serum creatinine level < 1.5 mg/dl, n = 25; Renal failure group, serum creatinine level > or = 1.5 mg/dl, n = 20) on the basis of renal function. Mean 24-hour, awake and asleep systolic blood pressure were 151.8 +/- 18.3(SD), 155.7 +/- 17.4 and 140.5 +/- 23.3 mmHg (Diabetes mellitus group) and 152.2 +/- 22.7, 152.6 +/- 22.1 and 150.0 +/- 26.5 mmHg (Renal failure group), respectively, which were higher(p < 0.01) than those(122.7 +/- 9.1, 126.0 +/- 10.2 and 112.9 +/- 10.7 mmHg) in age- and sex-matched control subjects(n = 20). The ratio between asleep and awake systolic blood pressure was 0.90 +/- 0.10 (Control group) and 0.90 +/- 0.11(Diabetes mellitus group), which were lower(p < 0.01) than that(0.98 +/- 0.09) in the Renal failure group. The Control and Diabetes mellitus groups showed a high awake mean LF/HF power ratio(1.91 +/- 0.55 and 1.95 +/- 0.48). On the other hand, the Renal failure group showed a low ratio (1.50 +/- 0.46) (p < 0.01), but each group showed no significant difference in the asleep mean LF/HF power ratio. These findings suggest that sympathovagal imbalance is worse in the waking hours in diabetic nephropathy patients with renal dysfunction, and this causes loss of the nocturnal decrease in blood pressure.

[Valvuloplasty for mitral regurgitation associated with acromegaly: report of a case].

A 67-year-old female with mitral regurgitation associated with acromegaly was admitted to our hospital. The cause of MR was torn chordae of posterior leaflet of the mitral valve. A prolapse part of the posterior leaflet was resected and sutured by McGoon's method. Annuloplasty was performed by Kay's method. Postoperative course was uneventful. She recovered well after the operation.

[Successful correction of incomplete endocardial cushion defects in an elderly patient].

We have experienced surgical correction of incomplete ECD in a 66-year-old female patient. This is the oldest case in Japanese literatures. Preoperative examination showed mild mitral regurgitation, interatrial shunt (L-R 52%) and moderate pulmonary hypertension (Pp/Ps 0.48). The correction consisted of valvuloplasty of mitral valve and patch closure of ostium primum. The postoperative course was uneventful. The postoperative catheterization showed improved cardiac function.

[A case report of aneurysm of the diverticulum of the ductus arteriosus].

A 59-year-old man who was admitted with hoarseness and diagnosed as aneurysm of the diverticulum of the ductus arteriosus was reported. In our case, enhanced computed tomography and aortography gave reliable informations. Operation was performed through a posterolateral thoracotomy under partial cardiopulmonary bypass. The aneurysm was successfully resected and defect of the aortic wall was covered with Dacron patch. Postoperative course was uneventful. To our knowledge, this is 12th surgically treated case in Japan.

[Total anomalous of pulmonary venous connection in infants less than 3 months old].

We examined the surgical results of total anomalous pulmonary venous connection (TAPVC) retrospectively in 6 infants, who were less than 3 months old and underwent a total repair at Ehime Prefectural Central Hospital between May, 1993 through May, 1998, in terms of the pre, peri, and postoperative management, the site of connection, and the surgical procedures. Aged at operation ranged from 1 day to 86 days (mean 39 days), and body weight ranged from 2.4 kg to 5.5 kg (mean 3.4 kg). All 6 patients had echocardiographic diagnosis and cardiac catheterization but one. In operative procedure, cut back method was done in a patient of paracardiac type of Darling's classification and posterior approach was used in total correction for 4 supracardiac and 1 infracardiac type. There were 3 hospital deaths who had poor conditions before operation, but no late deaths. Surgical results of TAPVC might have been improved with advances in non-invasive diagnosis by echocardiography, and pre and perioperative management. And we should take care of these patients of TAPVC in long term period to make sure that they have no pulmonary venous obstruction.

Efficacy of local dipyridamole therapy in a porcine model of arteriovenous graft stenosis.

Perivascular delivery of antiproliferative drugs has been proposed as an approach to prevent neointimal hyperplasia associated with hemodialysis polytetrafluoroethylene (PTFE) grafts. We examined this approach to deliver dipyridamole in a porcine graft model. PTFE grafts were implanted between the carotid artery and external jugular vein bilaterally in pigs. During the surgery or 1 week post-graft placement, dipyridamole (0.26-52 mg) alone or incorporated in microspheres was mixed with an injectable polymeric gel and applied to the graft-arterial and graft-venous anastomoses on one side, whereas the contralateral control graft received no treatment. Three or four weeks after operation, the grafts and adjacent vessels were explanted en bloc and cross-sections of the anastomoses were examined histologically. The degree of neointimal hyperplasia was quantified by planimetry. In separate experiments, dipyridamole was extracted from the explanted tissues and assayed by spectrofluorometry. The normalized median hyperplasia areas of the treated and control graft-venous anastomoses were 0.45 (25th-75th percentile, 0.30-0.86) and 0.24 (0.21-0.30), respectively (N=7; P=0.08). The median hyperplasia areas of the treated and control graft-arterial anastomoses were 0.12 (0.07-0.39) and 0.11 (0.09-0.13), respectively (N=7; P=0.31). The dipyridamole levels in the vascular walls around the anastomoses were at or above the in vitro inhibitory concentrations for approximately 3 weeks. These results suggest that the local perivascular sustained delivery of dipyridamole, even at high dosages, was ineffective in inhibiting neointimal hyperplasia associated with PTFE grafts in a porcine model.

Effects of doxazosin on ambulatory blood pressure and sympathetic nervous activity in hypertensive Type 2 diabetic patients with overt nephropathy.

AIMS: Few studies have reported the effect of alpha(1)-adrenergic antagonists on 24-h blood pressure (BP) and sympathetic nervous activity in hypertensive patients with diabetic nephropathy. We assessed the effects of doxazosin on 24-h BP and spectral analysis of heart rate variability in hypertensive Type 2 diabetic patients with macroalbuminuria and compared the results with those in hypertensive Type 2 diabetic patients with normoalbuminuria and non-diabetic patients with essential hypertension. METHODS: Thirty-three patients in the macroalbuminuric group, 24 patients in the normoalbuminuric group, and 34 patients with essential hypertension underwent ambulatory BP monitoring before and after doxazosin treatment. Spectral analysis was performed to calculate the high-frequency (HF) components, a marker of parasympathetic nervous activity, and the low-frequency (LF) components, a marker of sympathetic nervous activity. RESULTS: Doxazosin decreased waking (from 158 +/- 17/88 +/- 10 to 148 +/- 15/80 +/- 7 mmHg, P = 0.001 for systolic and P < 0.001 for diastolic BP) and sleeping BP (146 +/- 20/79 +/- 10 to 137 +/- 17/72 +/- 9 mmHg, P < 0.001 and P < 0.001) in the macroalbuminuric group, but only decreased waking BP in the essential hypertension group (157 +/- 16/91 +/- 9 to 145 +/- 15/84 +/- 11 mmHg, P < 0.001 and P < 0.001) and normoalbuminuric group (159 +/- 15/89 +/- 9 to 150 +/- 16/82 +/- 10 mmHg, P = 0.014 and P < 0.001). Doxazosin decreased waking (from 1.48 +/- 0.11 to 1.42 +/- 0.12, P = 0.001) and sleeping (1.46 +/- 0.11 to 1.40 +/- 0.13, P = 0.001) LF components [unit: log(ms(2)/Hz)] only in the macroalbuminuric group without changing HF components. The normoalbuminuric and essential hypertension groups showed no differences (P = 0.637 and 0.492) in LF components during sleep. CONCLUSIONS: Doxazosin may be an antihypertensive agent that decreases both waking and sleeping BP through inhibiting sympathetic nervous activity in macroalbuminuric diabetes patients.

[A case of mitral valve replacement for Libman-Sacks endocarditis].

A 38-year-old female was admitted to our hospital because she was suffered from severe dyspnea on effort. She had a history of nasal bleeding, endocarditis, fever, proteinuria, and alopecia at the age of 16, and was diagnosed as SLE. She was suffered from recurrent cerebral infarctions at the age of 35 and 38, and then mitral regurgitation was pointed out. Preoperative examination revealed non-active phase of SLE and UCG showed massive mitral regurgitation. Operative findings showed thrombosed verrucca circumferentially on the mitral valve. Mitral valve replacement (B-S #27) was done with using a felt strip in order to reinforce the mitral annular tissues. Histological findings of the verrucca showed Libman-Sacks endocarditis. Postoperative course was uneventful. Surgical treatment for Libman-Sacks endocarditis is extremely rare.

[A case of delayed ascending aortic pseudoaneurysm after traffic injury mimicking cardiac tumor].

A 44-year-old man was transferred to our hospital because of severe congestive heart failure complicated with acute renal failure and hepatic failure. He had been injured in a traffic accident three years before. Echocardiogram demonstrated a large tumor on the anterior wall of right ventricle obstructing RV outflow. Emergent operation was performed with cardiopulmonary bypass. Tumor was too large and invading into RV endocardium partially. RV patch enlargement was performed because it was impossible to resect tumor entirely. CVP was decreased dramatically to 8 cmH2O from 28 cmH2O. Postoperative hemodynamic was stable, but patient died of hepatic failure. Autopsy revealed that tumor was pseudoaneurysm from ascending aorta and ruptured into right ventricle.

Hepatic neoplasms: detection with hepatoportal subtraction angiography--a new technique of DSA.

A new technique for hepatic intraarterial digital subtraction angiography (DSA)--hepatoportal subtraction angiography (HPSA)--that emphasizes the enhancement of tumors by suppressing liver parenchymal enhancement has been developed. The tumor detection sensitivity of HPSA was evaluated prospectively in comparison with that of conventional hepatic intraarterial DSA, unenhanced computed tomography (CT) or CT enhanced with iodine-containing contrast material (conventional CT), CT with iodized oil, and ultrasound (US). For 84 detected lesions of hepatoma, the sensitivity of HPSA was 92%, statistically superior to the 71% of hepatic intraarterial DSA (P less than .002), the 42% of US (P less than .001), and the 39% of conventional CT (P less than .001) and nearly the same as the 90% of CT with iodized oil. Among 33 lesions of metastasis, HPSA depicted 91%; conventional CT, 93%; US, 87%; and hepatic intraarterial DSA, 76%. HPSA was more sensitive than hepatic intraarterial DSA, but the difference was not statistically significant. Compared with hepatic intraarterial DSA, HPSA enabled detection of more faintly enhanced tumors, and this technique was considered useful for detecting small hypervascular hepatic tumors.