An analytical technique for measuring protein carbonyl in the stratum corneum using surface plasmon resonance.

Protein carbonyl groups in the stratum corneum may be used as a biomarker for skin photo-stress. To evaluate the relationship between the protein carbonyl to total protein (TP) ratio (carbonylation ratio) and skin photo-stress, the authors established a methodology by which protein carbonyl can be easily and highly sensitively analysed using an optical technique based on surface plasmon resonance (SPR). To collect the stratum corneum, tape stripping was employed. Firstly, the protein carbonyl was reacted with 2,4-dinitrobenzenesulfonic acid dihydrate, and the quantity of dinitrophenylated (DNP)-protein carbonyl was determined using an anti-dinitrophenyl (anti-DNP) antibody. The mass of DNP-protein carbonyl was measured using SPR. A truncated sampling-reporting cycle of <5 min allowed speedy reporting of DNP-protein carbonyl levels. A significant difference was observed in the protein carbonyl/TP ratio (carbonylation ratio) between a sun-protected area (mid-ventral arm) and a sun-exposed area (upper cheek, P < 0.05). Additionally, the carbonylation ratio of the sun-exposed area showed a higher value than that of the sun-protected area. It was suggested that the carbonylation ratio might be a useful index of skin photo-stress.

[Safety and efficacy of autologous blood donation before elective off-pump coronary artery bypass grafting].

BACKGROUND: Preoperative autologous blood donation reduces exposure to homologous blood transfusions in cardiac surgery. The purpose of this study was to ascertain, how much volume of predonated autologous blood needed to avoid of homologous blood transfusion in scheduled off-pump coronary artery bypass grafting (OPCAB). METHOD: Fifty patients underwent scheduled OPCAB. These patients donated 400 ml (group A, n = 30) or 800 ml (group B, n = 20) of autologous blood before operation. These patients donated at a rate of 400 ml per week. All patients were given an equal volume of saline solution at the time of autologous donation. RESULT: There were no significant differences mean age, mean body weight, mean preoperative hematocrit values, mean graft number or mean volume of intraoperative blood loss between groups A and B. There was significant difference the mean postoperative day-7 hematocrit value (33.4 +/- 1.5% vs 38.7 +/- 1.5%, p < 0.05). The rates of avoiding homologous blood transfusion were 63.3% in group A and 100% in group B (p < 0.05). CONCLUSIONS: Autologous blood transfusion was effective for reducing the homologous blood requirement. We believe that 800 ml predonation is sufficient to avoid homologous blood transfusion in scheduled OPCAB, further patients with cardiovascular disease including severe coronary artery should be donated with the administration of saline.

[Cerebral oxygen desaturation monitoring during off-pump coronary artery bypass grafting].

BACKGROUND: The evaluation of cerebral perfusion during off-pump coronary bypass grafting (OPCAB) has not been clarified. The aim of this study was to investigate the predictive value of neurobiochemical markers of brain damage and cerebral perfusion with respect to the neuropsychological outcomes after OPCAB. METHODS: Ten patients (4 males and 6 females) underwent OPCAB. All patients were performed brain CT preoperatively and 7 days postoperatively. We excluded the patients with cerebralvascular disease from this study. A 5.5 Fr oximetric catheter was placed in the jugular bulb, and we measured continuously SjO2 and mean arterial blood pressure during OPCAB. Venous serum level of neuron specific enolase (NSE) was measured preoperatively and 24 hours after skin closure. RESULTS: There was correlation between mean blood pressure and SjO2 during anastomoses. The mean blood pressure during anastomoses of left anterior descending coronary artery (LAD), circumflex coronary artery (Cx), right coronary artery (RCA) were 68.6 +/- 12.9 mmHg, 60.9 +/- 9.3 mmHg, 64.1 +/- 14.1 mmHg. The SjO2 during anastomoses of LAD, Cx, RCA were 57.3 +/- 10.9%, 48.6 +/- 9.8%, 57.7 +/- 18.2%. There is tendency that the SjO2 during anastomosis of Cx was lower than others. No patients died, and there was no permanent neurologic deficit. Postoperatively, 2 patients had abnormal high NSE level. CONCLUSION: Intraoperative continuous cerebral oxygen desaturation monitoring seems to be useful monitor for neuropsychological outcomes after OPCAB.

[Preoperative autologous blood donation with cardiac surgery].

BACKGROUND: Preoperative autologous blood donation is commonly used to reduce exposure to homologous blood transfusions among patients undergoing elective cardiac surgery. The purpose of this study was to ascertain how much volume of predonated autologous blood need to avoid of homologous blood transfusion in cardiac procedure. METHODS: One hundred twenty-eight patients underwent scheduled cardiac procedure between January 1998 and December 1999. Group 1: 400 ml predonated, operation without cardiopulmonary bypass (CPB) [n = 33], group 2: 800 ml predonated, operation without CPB (n = 23), group 3: 800 ml predonated, operation with CPB (n = 36), group 4: 1,200 ml predonated, operation with CPB (n = 36). Surgical procedures underwent only off-pump coronary artery bypass grafting (OPCAB) in groups 1 and 2. In groups 3 and 4 included coronary artery bypass grafting (CABG), valve replacement, CABG + valve replacement and atrial septal defect repair. RESULTS: There were no significant differences in mean body weight, mean preoperative hematocrit values or mean volume of intraoperative blood loss between groups 1 and 2. There were no significant differences in mean age, mean body weight, mean preoperative and postoperative day-7 hematocrit values, mean volume of intraoperative blood loss or mean CPB time between groups 3 and 4. The mean postoperative day-7 hematocrit value was significantly lower in group 1 than in group 2. Homologous blood transfusion was avoided in 63.6% of those with predonation of group 1 versus 100% at group 2 (p < 0.05), 86.1% at group 3 versus 94.4% at group 4 (p < 0.05). In group 3, all patients who underwent redo operation or CABG + valve replacement needed homologous blood transfusion. CONCLUSIONS: Autologous blood transfusion is effective for reducing the homologous blood requirement. It also seems that predonation of 800 ml may be sufficient to avoid homologous blood transfusion in cardiac surgery, however predonation of 1,200 ml is desirable in cases of redo operation or CABG + valve replacement.

Prediction of improvement in regional left ventricular function after coronary artery bypass grafting: quantitative stress-redistribution 201Tl imaging in detection of myocardial viability.

BACKGROUND: This study investigated the usefulness of quantitative assessment of Thallium-201 stress redistribution myocardial scintigraphy combined with quantitative assessment of regional left ventricular function using the centerline method for predicting of recovery regional left ventricular function following myocardial revascularization. METHODS: Twenty patients with chronic total obstruction of the proximal portion of left anterior descending artery and/or right coronary artery were studied. Percent Tl-uptake method was used to evaluate myocardial viability before CABG. Regional LV function was evaluated before and after CABG with the centerline method. The territory of LAD was defined by chords 10 to 58 and that of RCA was defined by chords 59 to 80 in the centerline method. The parameter of regional left ventricular function was the mean (SF-Av.)/SD of each LAD and RCA territory. RESULTS: In cases showing a % uptake value under 50%, the preoperative value of (SF-Av.)/SD was -3.18+/-0.74 and postoperative value was -2.63+/-0.8 1. The difference between these values was not significant. When the %uptake value over 50%, the preoperative value of (SF-Av.)/SD was -2.80+/-0.49 and the postoperative value was -2.27+/-0.28. The postoperative value was significantly higher than the preoperative value(p=0.007). CONCLUSIONS: Even in cases of severe left ventricular dysfunction, regional left ventricular function improved if the value of % uptake in the redistribution Thallium imaging was 50% or over. Quantitative analysis of myocardial scintigraphy combined with quantitative analysis of left ventriculography is a useful method for predicting recovery of regional left ventricular function following myocardial revascularization.

[Surgical angioplasty of isolated left coronary ostial stenosis].

A 42-year-old female had suffered from chest pain for approximately 1 month, and was admitted with unstable angina pectoris. Emergent coronary angiography showed an isolated 75% stenosis of the left coronary ostium. Repair of ostial stenosis by vein patch angioplasty was done by the transactional superior approach. Postoperative catheterization revealed an expanded left coronary orifice and the patient was discharged without any complications. We have experienced 2 other patients of isolated left coronary ostial stenosis, who had undergone double coronary artery bypass grafting. Long-term coronary angiography showed regression of ostial stenosis in 1 patient, and no progression of new lesions in either. These results suggest that direct vein patch angioplasty of the ostial lesion is an alternative procedure for isolated left coronary ostial stenosis.

Mitral valve replacement in ischemic mitral regurgitation. Preservation of both anterior and posterior mitral leaflets.

BACKGROUND: The surgical risks associated with ischemic mitral regurgitation are thought to be greater than those for other forms of mitral regurgitation. We have performed mitral valve replacement using the St. Jude Medical bileaflet prostheses with preservation of both leaflets, along with all of the chordae tendineae and papillary muscles. The aim of this study was to retrospectively evaluate mitral valve replacement with preservation of both mitral valves with respect to long-term clinical results and left ventricular performance. METHODS: Between January 1, 1988 and February 29, 2000, 15 patients were operated on for ischemic mitral regurgitation. There were 7 males and 8 females, and the mean age was 69.7+/-8.1 years. The preoperative variables showed clinical deterioration of the state, such as emergency operation in 40% of the patients, more than NYHA functional III class in 93% of patients, cardiogenic shock in 47% of the patients, a mean left ventricular ejection fraction of 36.8%, and a mean left ventricular end-systolic volume index of 116.7 ml/m2. RESULTS: There were 5 (33.3%) hospital deaths during the follow-up period including 1 early death and 1 (10%) late death during the follow-up period. Thus, the actuarial survival rate after 5 years for the whole was 60%. However, the left ventricular dimensions and left ventricular fractional shortening, even if in patients with profound depressed left ventricular function preoperatively, showed maintenance of the cardiac function. CONCLUSIONS: These results suggested that mitral valve replacement using the St. Jude Medical prostheses with preservation of both leaflets and all chordae tendineae and papillary muscles might be a procedure of choice for ischemic mitral regurgitation.

Staged coronary artery bypass grafting after percutaneous angioplasty for intracranial vascular stenosis.

OBJECTIVE: Cerebrovascular disease is commonly associated with coronary artery disease and is a major risk factor for cardiac surgery. Concomitant coronary artery bypass grafting and carotid endarterectomy may reduce the risk of stroke; however, this staged operation is effective only for extracranial lesions. The strategy for on-pump coronary artery bypass grafting for patients with intracranial vascular stenosis is still controversial. METHODS: The subjects were 157 consecutive candidates for coronary artery bypass grafting who underwent computed tomography and digital subtraction cerebral angiography preoperatively to check for cerebrovascular disease. Additional single-photon emission computed tomography was performed to evaluate cerebral ischemia, according to the neurologist's request. Patients with diffuse intracranial vascular stenosis impossible to treat with percutaneous transluminal angioplasty underwent off-pump coronary artery bypass grafting. Patients with a circumflex coronary artery lesion first underwent percutaneous transluminal angioplasty for cerebral vascular stenosis followed by secondary on-pump coronary artery bypass grafting. RESULTS: Three patients were selected for staged operations. Percutaneous transluminal angioplasty was performed for 4 intracranial stenotic lesions. All lesions were dilated successfully, and no complications developed during or after the procedure. All patients tolerated staged coronary artery bypass grafting and were extubated within 1 day without any mental disturbance. No further neurologic complication occurred, and computed tomography performed postoperatively revealed no significant changes. CONCLUSION: Staged on-pump coronary bypass after percutaneous transluminal angioplasty for cerebrovascular disease may reduce the risk of stroke during cardiopulmonary bypass, and it is useful especially in patients with intracranial cerebrovascular disease.

Ascending aorta dissection associated with bicuspid aortic valve. Considerations 4 years after combined coronary artery bypass grafting and mitral valve replacement.

Aortic dissection etiology involve many factors that are difficult to identify clearly. We report a 47-year-old man who underwent a Bentall operation with reattachment of bypass grafts for a dissecting aneurysm (DeBakey type II) 4 years after combined triple coronary artery bypass grafting and mitral valve replacement. This case appeared to be associated with factors leading to dissecting aneurysm although it remains unclear which was more influential congenital bicuspid aortic valve or proximal anastomosis of venous grafts or both. This case suggests the need to consider appropriate timing in surgical intervention for cases of congenital bicuspid aortic valves and the selection of additional aortic valve replacement in initial surgery.

[A case of thrombosed St. Jude Medical valve 16 years after initial mitral valve replacement].

We report successful surgery for a thrombosed St. Jude Medical (SJM) valve 16 years after the initial mitral valve replacement even under conditions of satisfactory anticoagulation therapy. A 61-year-old-female had intermittent claudication and was admitted to our hospital for examination. The prosthetic valve sounds were normal to auscultation and the left ankle-pressure index was decreased to 0.6. Transthoracic echocardiography revealed no mitral regurgitation and a mean mitral valve gradient of 6-7 mmHg. Furthermore, transesophageal echocardiography revealed that one of the leaflets of the prosthetic valve was entirely immobilized at the closing position and a mobile soft tissue mass, 5 mm in diameter, was detected at the atrial side of the obstructed leaflet. Although 96,0000 IU of urokinase was administered intravenously for a week, we could not confirm any change in leaflet mobility. At the time of surgery, the posterior leaflet of the SJM valve, which was implanted at an anatomical orientation, was obstructed at the closing position with old and fresh thrombi. We decided upon replacement with a CarboMedics 29 M prosthetic valve. Postoperative medication consisted of warfarin plus low-dose aspirin. Generally, valve thrombosis occurs within 5 years after valve replacement. However, valve thrombosis is possible even in a reliable SJM valve and as long as 16 years after replacement. Therefore, the implantation of an SJM valve at an anti-anatomical orientation might lower the incidence of valve thrombosis in addition to life-long anticoagulation therapy.

[Preoperative autologous blood donation in elderly patients with cardiovascular surgery].

BACKGROUND: During the cardiovascular surgeries in elderly people, only a few cases can avoid the homologous blood transfusion, because of their preoperative anemic tendency and low hemopoietic abilities. We examined the capability to avoid the homologous blood transfusion in over 75 year old patients by the preoperative autologous blood collection. Sixty-six patients underwent scheduled cardiovascular surgery between January 1996 and December 1999. The groups were divided into three categories of preoperatively collected autologous blood amounts: high-amount (800-1,200 ml), medium-amount (200-800 ml), and low-amount (0 ml). Each group was divided into two subgroups in according to the use of cardiopulmonary bypass (CPB). There were no differences among the each group in age, body weight, or preoperative and postoperative day-7 hematocrit values. RESULTS: Only 21.2% of patients could donate the expected blood amounts preoperatively. Mean volume was 641 ml. In groups used CPB, no patient was transfused homologous blood in high-amount group. On the contrary, 100% patients were donated in medium and low amount groups. In groups operated without CPB, homologous blood transfusion was required 14.3% in high-amount group, 25.0% in medium-amount group, and 83.3% in low-amount group. CONCLUSION: It seems that predonation of more than 800 ml may be sufficient to avoid the homologous blood transfusion in using CPB operation and more than 400 ml in non using CPB operation.

Initial experience with off-pump coronary artery bypass grafting.

Off-pump coronary artery bypass grafting (OPCAB) is clearly preferable for patients with extracardiac complications. The aim of this study was to evaluate the initial outcome of OPCAB, and its validity for patients with extracardiac complications. One hundred and fifty-seven consecutive coronary artery bypass graft (CABG) patients were divided into two groups: 30 OPCAB patients and 127 on-pump CABG patients. The early outcomes of the two groups were compared. Preoperatively, OPCAB patients had more extracardiac risk factors than on-pump CABG patients. There were no differences in age or cardiac function between the groups, but the off-pump group had a higher incidence of previous surgery, cerebrovascular disease, and renal failure. There were no differences in graft patency, stroke, or mortality between the two groups, even though the OPCAB patients had more risk factors than the on-pump patients. Our initial experience with OPCAB showed that it is acceptable for high-risk patients in view of the serious nature of their extracardiac condition.

X-linked dilated cardiomyopathy with a large hot-spot deletion in the dystrophin gene.

A 36-year-old Japanese man was hospitalized with coughing and exertional dyspnea (NYHA class I). He was diagnosed as having congestive heart failure, and was treated with diuretics and a beta-adrenergic blocking agent. He responded well to the treatment and his symptoms completely disappeared within a few days. Based on his clinical, laboratory, and molecular genetic findings, he was diagnosed as having X-linked dilated cardiomyopathy (XLDCM). He was found to have a large deletion in the dystrophin gene, involving exons 45-55. This is the first report on a Japanese XLDCM patient with a mutation in the central hot-spot region of this gene.

Usefulness of the subendocardial myocardial velocity gradient in low-dose dobutamine stress echocardiography.

The subendocardial side of myocardium makes a major contribution to left ventricular (LV) contraction and is very susceptible to ischemia. In this study we sought to quantify regional wall motion during low-dose dobutamine stress echocardiography (DSE) by using the myocardial velocity gradient (MVG) derived from tissue Doppler imaging (TDI). We then compared the usefulness of subendocardial MVG with that of transmural MVG in detecting subtle wall motion abnormalities. Fourteen patients (single vessel disease = 6; normal coronary arteries = 8) underwent low-dose DSE (10 microg/ kg per min). M-Mode TDI of the LV posterior wall was recorded using a Toshiba SSA-380A combined with custom computer software, and analyzed for both subendocardial and transmural MVG. Visual estimation and transmural MVG failed to clearly demonstrate the differing responses between the nonischemic (systole: 3.0 +/- 0.8/s to 4.9 +/- 1.9/s, not significant; diastole: -4.3 +/- 1.3/s to -5.7 +/- 1.4/s, not significant; mean +/- SD, P versus ischemic segments) and ischemic (systole: 3.3 +/- 1.2/s to 3.8 +/- 1.0/s; diastole: -5.4 +/- 2.0/s to -5.3 +/- 1.1/s) segments during low-dose DSE. Subendocardial MVG demonstrated a significant change in the nonischemic segments (systole: 4.1 +/- 1.0/s to 7.7 +/- 2.2/s, P = 0.012; diastole: -6.5 +/-1.8/s to -11.3 +/- 2.2/s, P = 0.001), whereas the response remained unchanged in the ischemic segments (systole: 4.6 +/-2.4/s to 4.8 +/- 1.2/s; diastole: -7.0 +/- 1.9/s to -7.3 +/- 1.1/s). Subendocardial MVG, particularly diastolic subendocardial MVG, may serve as a useful indicator of subtle ischemic changes in wall motion induced by low-dose DSE.

Percutaneous cardiopulmonary support as a bridge to emergency operation--two surviving cases.

Two patients had percutaneous cardiopulmonary support (PCPS) used as a bridge to emergency surgery. A 66-year-old man admitted with profound cardiogenic shock underwent direct stenting under PCPS with the diagnosis of acute myocardial infarction of the left main trunk, with the intention of performing revascularization as soon as possible. Subsequently, double coronary artery bypass grafting was successfully accomplished. A 69-year-old woman, admitted with acute heart failure due to critical aortic stenosis, manifested cardiogenic shock while undergoing catheterization. PCPS was immediately instituted until the acute deterioration of her hemodynamic state could be reversed, and was continued uneventfully till aortic valve replacement was performed. These results suggest that the current PCPS system is an effective response to acute circulatory collapse and will contributed to the improved survival of patients.

Surgical angioplasty of ruptured left anterior descending coronary artery without cardiopulmonary bypass.

We report a case of successful off-pump surgical angioplasty in the left anterior descending coronary artery using a saphenous vein patch. A 49-year-old male with left main disease and severe cerebrovascular stenosis underwent off-pump bypass to the left anterior descending artery. Postoperative angiography showed anastomotic stenosis where balloon angioplasty was performed. However, it resulted in coronary perforation complicated with epicardial tamponade, and emergency off-pump surgical angioplasty was performed. This case demonstrated that coronary arterial rupture could be managed by surgical angioplasty without cardiopulmonary bypass when coronary artery perforation occurred.

[Management of patient with acute myocardial infarction due to left main trunk obstruction].

Between April 1995 and March 1998, we experienced 13 cases of Acute Myocardial Infarction due to Left Main Trunk Obstruction (LMT-AMI). Two cases died before emergent intervention. Eight cases underwent emergent intervention (Plain Old Balloon Angioplasty (POBA) in five cases, Stenting in 3 cases); 2 cases died of acute occlusion of POBA site, 1 case survived by only POBA, and the other 5 cases underwent following Coronary Artery Bypass Grafting (CABG). 3 cases underwent only CABG with stable hemodynamics condition by Intraaortic balloon pumping (IABP) support. In a result, seven of eight CABG cases survived. Emergent stenting made the hemodynamics before CABG stable, and six-month's follow up angiogram showed occluded bypass grafts and patent stented sites in two of three cases. The combination therapy of emergent stenting and CABG will have to be evaluated in future.

[Reoperative off-pump subclavian-coronary artery bypass grafting in an elderly patient with left internal thoracic artery stenosis].

A 80-year-old Japanese female was diagnosed to have angina pectoris and admitted to our hospital. She had been operated on with mitral valve replacement and coronary artery bypass grafting to right and circumflex coronary artery 4 years before. The coronary angiogram showed significant stenosis with severe calcification in the left anterior descending coronary artery, and it was unsuitable for catheter intervention. The patient also had stenotic left internal thoracic artery and multiple cerebral infarction, but successful off-pump subclavian-coronary artery bypass grafting using saphenous vein graft through small thoracotomy was performed without new neurological deficit. This procedure is useful for patients with left internal thoracic artery unsuitable for MIDCABG, due to quality, size, or injury during preparation.

[A combination of reoperation for pseudoaneurysm following the Cabrol procedure and total aortic arch replacement in a patient with Marfan syndrome--a case with an aberrant right subclavian artery].

A 44-year-old male with Marfan's syndrome had undergone an initial operation for DeBakey type I acute aortic dissection with annulo-aortic ectasia. He had undergone replacement of the ascending aorta and aortic valve with a composite graft and reconstruction of the coronary artery by the Cabrol procedure. At 5 years after the initial surgery he experienced chest pain and was subsequently examined. Computed tomography revealed a pseudoaneurysm in the ascending aorta and the residual aortic dissection. The maximum diameter of the pseudoaneurysm was 85 mm and the maximum diameter of the aortic arch was 55 mm. The aortic arch was associated with an aberrant right subclavian artery. Angiography revealed that the pseudoaneurysm was caused by leakage at the coronary ostium-graft anastomoses. We repaired the anastomoses and performed total aortic arch replacement with reconstruction of four arch branches. The postoperative course was uneventful without any complications. We report this case because there have been few reports regarding arch replacement in cases with an aberrant right subclavian artery.