PF1163A and B, new antifungal antibiotics produced by Penicillium sp. I. Taxonomy of producing strain, fermentation, isolation and biological activities.

Two novel antifungal antibiotics, PF1163A and B, were isolated from the fermentation broth of Penicillium sp. They were purified from the solid cultures of rice media using ethyl acetate extraction, silica gel and Sephadex LH-20 column chromatographies. PF1163A and B showed potent growth inhibitory activity against pathogenic fungal strain Candida albicans but did not show cytotoxic activity against mammalian cells. These compounds inhibited the ergosterol biosynthesis in Candida albicans.

PF1163A and B, new antifungal antibiotics produced by Penicillium sp. II. Physico-chemical properties and structure elucidation.

The structures of new antifungal antibiotics, PF1163A and B, were elucidated by spectroscopic analyses of the degradation products and by X-ray crystallography of the de-2-hydroxyethyl derivative of PF1163B. Both antibiotics consist of a 13-membered macrocyclic structure containing a derivative of N-methyl tyrosine and a hydroxy fatty acid. PF1163A differs from PF 1163B by having an additional hydroxyl group on the side chain.

[Determinants of long-term outcome for operative survivors of acute aortic dissection].

Predictability of aorta-related complications and survival was examined in 79 operative survivors of acute aortic dissection. Follow-up was 94.9% complete and totaled 458 patient-years. Actuarial survival was 93 +/- 3% (+/- S.E.) (n = 43) at 5 years, and 74 +/- 8% (n = 13) at 10 years. Survival was significantly lower in patients having neurological complication. Freedom from aorta-related complications was 82 +/- 5% (n = 37) at 5 years, and 67 +/- 8% (n = 11) at 10 years. Multivariate Cox regression analysis identified residual entry and leak on anastomotic site as independent predictors of aorta-related complications. We conclude that in the treatment of acute aortic dissections, reducing the incidence of residual entry and leak on anastomotic site improves long-term outcome.

[Serial changes in mitral regurgitation after mitral valve repair with artificial chordae tendineae: assessment by transesophageal echocardiography].

Serial changes in mitral regurgitation after anterior mitral valve repair were examined by transesophageal echocardiography (TEE) in 34 of 86 consecutive patients with pure mitral regurgitation who underwent anterior mitral valve repair from 1987 to 1996. The patients were divided into two groups: 15 patients undergoing mitral repair with polytetrafluoroethylene (PTFE; PTFE group) and 19 undergoing conventional mitral repair without PTFE (non-PTFE group). The PTFE group included 11 men and 4 women with a mean age of 52.1 years. They were followed for mean 22.8 +/- 12.0 months. The non-PTFE group included 12 men and 7 women with a mean age of 53.9 years. They were followed for mean 33.9 +/- 20.4 months. Mitral regurgitation jet areas were observed at the time of operation, 1 month after mitral valve repair, and in the late follow-up period. Regurgitation jet areas were 0.7 +/- 0.7, 1.1 +/- 0.9 and 2.5 +/- 2.1 cm2 in the PTFE group, and 1.1 +/- 1.3, 2.4 +/- 1.7, 4.7 +/- 2.9 cm2 in the non-PTFE group. The jet area was significantly smaller in the PTFE group than in the non-PTFE group at 1 month after operation and in the late follow-up period. Moderate to severe regurgitation was observed in two patients (13.3%) in the PTFE group, and eight patients (42.1%) in the non-PTFE group. Mitral valve repair with PTFE showed better results than conventional mitral valve repair without PTFE during the mean follow-up period of 23 months.

[Long-term results of mitral valve repair with artificial chordae tendineae].

The long-term results of mitral valve repair using artificial polytetrafluorethylene (PTFE) chordae were assessed in 61 consecutive patients with pure mitral regurgitation who underwent mitral valve repair with replacement of elongated or ruptured chordae tendineae between 1992 and 1996. There were 36 men and 25 women aged from 14 to 73 years (mean 52.1 +/- 13.8 years). The patients were followed up for between 1 to 73 months (mean 29.3 +/- 17.6 months). Fifty-five patients underwent mitral valve repair of the anterior leaflet and 6 repair of the posterior leaflet. There were two hospital and two late deaths. Actual survival rate at 5 years was 93.1%. Freedom from cardiac events at 5 years was 87.8%. Two patients required reoperation due to hemolysis. There were three occurrences of non-fatal thromboembolism. Although further investigation is necessary in a large population, expanded PTFE sutures are excellent for chordal replacement during mitral valve repair.

[Intraoperative assessment of mitral valve plasty by transesophageal echocardiography].

Mitral valve repair offers many advantages over prosthetic valve replacement, especially in minimizing the risk of thromboembolism. Intraoperative evaluation of residual mitral regurgitation (MR) is important in this procedure. The present study assessed the usefulness of transesophageal echocardiography (TEE) for the intraoperative assessment of residual MR in patients undergoing mitral valve repair. Intraoperative TEE was performed in 102 consecutive patients before and after mitral valve repair in the operating room. The grade of MR was evaluated according to the maximum MR jet area detected by biplane color Doppler TEE (mild: <4 cm2; moderate: 4 < or = < 7 cm2; severe : 7 cm2 < or =). After the first repair, the manual regurgitant test was performed. Excellent results with no or mild MR assessed by the manual regurgitant test were obtained in 101 patients. However, moderate or severe MR was identified in eight of these 101 (7.9%) patients by TEE after weaning from the cardiopulmonary bypass. Consequently, six of these eight patients underwent repeat mitral valve repair and two patients received prosthetic valve replacement. Satisfactory final operative results were obtained in all 101 patients. The eight patients who needed additional operative procedures followed good clinical courses in hospital. TEE 1 month after operation demonstrated no or mild MR in these eight patients. Intraoperative TEE is useful in the evaluation of residual MR after mitral valve repair. This technique provides indications for immediate additional operative procedures, and can reduce the occurrences of congestive heart failure and reoperation in the early stage after mitral valve repair.

[Serial change of mitral regurgitation after anterior mitral valve repair using polytetrafluorethylene chordae: evaluation by transesophageal echocardiography].

The results of anterior mitral leaflet repair were evaluated by the serial change of mitral regurgitation (MR) using transesophageal echocardiography (TEE) in 24 patients undergoing mitral valve repair for anterior leaflet prolapse during 1988 to 1994, who were examined by TEE immediately after operation, 1 month after operation, and late after operation (mean 15 months). Chordal replacement using polytetra-fluorethylene chordae was performed in 15 patients (PTFE group), and not performed in 9 patients (non-PTFE group). MR jet area late after operation was significantly smaller in the PTFE group than in the non-PTFE group (2.2 +/- 2.3 vs. 4.6 +/- 2.3 cm2, p < 0.05). Moderate to severe MR was observed in four patients (27%) in the PTFE group, and six (67%) in the non-PTFE group late after operation. The thickness of the mitral leaflet before operation was more than 5 mm in all patients with more than moderate MR late after operation in the PTFE group. Chordal replacement using polytetrafluorethylene chordae showed better results compared with conventional mitral valve repair without polytetrafluorethylene chordae over the follow-up period of 15 months.

Serial change of mitral regurgitation after mitral valve repair: comparison of anterior with posterior leaflet lesions.

Mitral valve repair is an important operative procedure for correcting mitral regurgitation (MR). However, serial change of residual MR after operation has not been reported. Serial change of MR after mitral valve repair was evaluated by transesophageal color Doppler echocardiography (TEE). Twenty-six patients undergoing mitral valve repair for MR during 1987 to 1991 were examined by TEE just after operation, 6 months after operation, and late follow-up period (mean 3.7 years). Thirteen patients had a lesion of the anterior mitral leaflet before operation (group A). Thirteen patients had a lesion of the posterior mitral leaflet before operation (group P). The MR area was measured by TEE at each stage after operation. In group A, the MR area at late follow-up increased significantly compared with just after operation (1.1 vs 4.3 cm2, p < 0.001). In group P, the MR area at late follow-up did not increase significantly compared with just after operation (0.6 vs 1.3 cm2, p = NS). In conclusion, MR does not increase after mitral valve repair in patients with posterior mitral valve repair, but MR may increase at late follow-up after operation for anterior mitral valve prolapse.

[Valvuloplasty for aortic insufficiency in a patient with bicuspid aortic valve].

A 20-year-old man with a bicuspid valve underwent aortic valvuloplasty for aortic regurgitation. Valvuloplasty was performed according to Cosgrove's method. Intraoperative transesophageal color Doppler echocardiography showed trivial aortic regurgitation after the repair. Peak pressure gradient across the repaired aortic valve was 9.3 mmHg at rest (cardiac output 4.2 l/min, stroke volume 49 ml) and 27.6 mmHg at dobutamine infusion (cardiac output 8.7 l/min, stroke volume 78 ml). The patient was in NYHA class I with no medication after surgery. Valvuloplasty for aortic regurgitation with a bicuspid valve is the surgical procedure of choice.

[A case of cardiac herniation following intrapericardial pneumonectomy after induction chemoradiotherapy].

A case of cardiac herniation following left intrapericardial pneumonectomy after induction chemoradiotherapy has been presented. Curative resection after induction chemoradiotherapy for central bronchogenic cancer may require intrapericardial pneumonectomy. Cardiac herniation through the pericardial defect is a fatal complication after a pneumonectomy unless pericardial repair should be done immediately. Closure of the pericardial defect with prosthetic patch, regardless of defect size, is always necessary for the prevention of the cardiac herniation following intrapericardial pneumonectomy after induction chemoradiotherapy.

[Mitral valve repair for infectious endocarditis].

Fourteen patients with mitral regurgitation resulting from infectious endocarditis underwent mitral valve repair between December 1988 and July 1994. There were nine males and five females aged from 14 to 70 years (mean 40.2 +/- 19.7 years). Three patients had active endocarditis. Time between the onset of endocarditis symptoms and surgery ranged from 1 to 24 months (mean 8.3 months). Bacterial findings were Streptococcus in eight patients, Staphylococcus in one, and unknown in five. All macroscopically infected tissue was excised in patients with active endocarditis. Carpentier's reconstructive techniques were mainly used. There were no hospital deaths. Mean follow-up was 29 months and complete. Thirteen patients were in New York Heart Association functional class I and one in class II. There were no late deaths, reoperations, recurrent endocarditis, thromboembolic events, or other valve-related morbidity. We conclude that mitral valve repair is an attractive procedure in patients with mitral regurgitation resulting from infectious endocarditis.

[Treatment of aneurysm of aortic arch using selective cerebral perfusion].

The objective of this study is to evaluate safety and efficacy of the selective cerebral perfusion (SCP) for an adjunct to perform operation of aortic arch aneurysms. From November 1982 to June 1993, surgical treatment of aneurysm of aortic arch using SCP was performed in 22 patients. The hospital death was accounted in 5 cases (23%), the intraoperative stroke was observed in 3 cases (14%) and these patients died. The cause of intraoperative stroke was cerebral hypoperfusion due to multiple sclerosis of intracranial arteries or insufficient SCP. Variables of an increased operative risk seemed to be older age (over 70 y.o.) and rupture. SCP time more than 120 minutes did not promote the operative risk. Cerebral hypoperfusion was directly responsible for not only intraoperative stroke, but also operative death. Therefore, SCP seems effective and safe if hypoperfusion is prevented.

Comparison of the Carpentier and Duran prosthetic rings used in mitral reconstruction.

This clinical study was undertaken to evaluate the Duran flexible ring and the Carpentier rigid ring in terms of mitral annulus motion, transmitral flow and left ventricular function. Twenty-six patients (11 receiving rigid rings and 15, flexible rings) with normal sinus rhythm and with no or only trivial mitral valve regurgitation after surgical repair were selected. Angiograms demonstrated no significant differences in left ventricular systolic function between the two groups of patients. The area of the mitral annulus with the flexible ring significantly changed during the cardiac cycle. There were significant differences in the left ventricular fractional shortening (rigid ring, 35.8%; flexible ring, 43.4%) and in the peak velocity (rigid ring, 222 cm/s; flexible ring, 186 cm/s) at peak exercise. These data suggest that the flexible ring interferes less with the normal movements of the mitral annulus during the cardiac cycle, and that, under exercise conditions, it performs better than the rigid ring. We therefore conclude that mitral valve reconstruction using the Duran flexible ring is advantageous in patients with mitral regurgitation due to degenerative disease and sinus rhythm.

Flow capacity of internal mammary artery grafts: early restriction and later improvement assessed by Doppler guide wire. Comparison with saphenous vein grafts.

OBJECTIVES: The purpose of this study was to assess flow dynamics and flow capacities of internal mammary artery and saphenous vein grafts to the left anterior descending coronary artery. BACKGROUND: The postoperative flow capacity of internal mammary artery grafts to the left anterior descending coronary artery has been reported to be restricted compared with that of saphenous vein grafts in studies using radionuclide angiography. A recently developed Doppler guide wire has been used to analyze the flow dynamics of bypass grafts and to clarify the mechanism of this limited flow capacity. METHODS: Phasic flow velocity recordings were obtained in the midportion of the bypass graft and within the native left anterior descending artery, using a 0.018-in. (0.046-cm) 12-MHz Doppler guide wire, in 53 patients: 27 patients with an internal mammary artery graft (16 with a new graft assessed 1 month postoperatively and 11 with an old graft assessed at 1 year) and 26 patients with a saphenous vein graft (13 with a new graft assessed 1 month postoperatively and 13 with an old graft assessed at 1 year). All patients were studied at baseline rest and during hyperemia induced by intravenous infusion of dipyridamole, 0.56 mg/kg body weight, over 4 min. RESULTS: In the left anterior descending artery itself, systolic and diastolic peak velocities, the time average of the instantaneous spectral peak velocity (time-averaged peak velocity), vessel diameter and the calculated flow volume did not differ significantly among the four graft groups. The time-averaged peak velocity was significantly greater for new than for old arterial grafts or for new or old vein grafts (mean +/- SD 27 +/- 9 vs. 19 +/- 6, 11 +/- 5 and 12 +/- 6 cm/s, respectively, p < 0.01). However, because the diameter of new arterial grafts was significantly smaller than that of the other three grafts (2.4 +/- 0.1 vs. 2.9 +/- 0.2 [p < 0.05], 3.6 +/- 0.6 [p < 0.01] and 3.4 +/- 0.5 mm [p < 0.01], respectively), there was no difference in calculated flow volumes at rest (62 +/- 17 vs. 58 +/- 15, 61 +/- 18 and 58 +/- 19 ml/min, respectively, p = NS) between new arterial grafts and the other grafts. Although the maximal time-averaged peak velocity during hyperemia was significantly greater in new than in old arterial grafts or new or old vein grafts (47 +/- 17 vs. 40 +/- 7, 31 +/- 8 and 34 +/- 12 cm/s, respectively, p < 0.01), the flow reserve of new arterial grafts was significantly smaller than that of the other three groups (1.8 +/- 0.3 vs. 2.6 +/- 0.3, 2.8 +/- 0.5 and 3.0 +/- 0.6, respectively, p < 0.01) because the baseline time-averaged peak velocity of these new grafts was far greater than that of the other groups. CONCLUSIONS: Internal mammary artery graft flow early after operation is characterized by a higher rest velocity than that of vein graft flow. This high velocity maintains flow volume at baseline condition in compensation for the smaller diameter. Although flow reserve does not differ significantly between new and old vein grafts, that for internal mammary artery grafts is significantly reduced soon after bypass surgery. This restricted flow capacity improves late postoperatively because of an increase in diameter and a decrease in flow velocity from baseline levels.

[Residual, recurrent mitral regurgitation after mitral valve reconstruction: differences in lesion and operation method].

Patients developing residual or recurrent mitral regurgitation (MR) increased to moderate or severe grade after mitral valve reconstruction for MR were investigated by correlating the lesion and operation method with the echocardiographic course of postoperative MR. Postoperative moderate or severe grade MR [more than 4.0 cm2 color Doppler flow area on postoperative transesophageal echocardiography (TEE)] occurred in 21 of 80 mitral valve reconstruction patients. If residual MR caused more than 2.0 cm2 color Doppler flow area on intraoperative TEE, the MR increased to moderate or severe grade during the follow-up period. Postoperative moderate or severe MR occurred more frequently in lesions of the anterior mitral leaflet than the posterior mitral leaflet (45.8% vs 6.5%, p < 0.001), and in elongated chordae than in torn chordae (52.9% vs 14.3%, p < 0.005). Chordal shortening for elongated chordae could correct MR at operation but MR recurred and increased gradually to moderate or severe grade in half of these cases. Chordal reconstruction with polytetrafluorethylene suture is expected to achieve better results than chordal shortening. The causes of postoperative MR could usually be identified by comparative investigation of echocardiographic course, lesion, and operation method. Postoperative moderate or severe MR occurs more often in lesions of the anterior mitral leaflet or cases of elongated chordae. Residual MR should be suppressed to less than 2.0 cm2 color Doppler flow area on intraoperative TEE.