N-terminal pro-brain natriuretic peptide and associated factors in the general working population: a baseline survey of the Uranosaki cohort study.

Few data on clinical characteristics associated with N-terminal pro-brain natriuretic peptide (NT-proBNP) or the clinical value of measuring NT-proBNP in the working population are available. The aim of the present study was to investigate the levels of NT-proBNP and their association with clinical variables in the Japanese general working population by using baseline data from the Uranosaki cohort study. In the study, the plasma concentration of NT-proBNP and some biomarkers were measured in addition to the standard health checkups at the workplace. Questionnaires regarding health-related quality of life (HR-QOL) were also completed. A total of 2140 participants were enrolled in the study. Plasma levels of NT-proBNP were positively associated with age, female sex, systolic blood pressure, pulse pressure, prevalent hypertension, smoking habit, high-density lipoprotein cholesterol (HDL-C), and prevalent proteinuria, and negatively associated with body mass index, lipid profiles except HDL-C, uric acid, renal function, and hemoglobin. Both the plasma concentration of high-molecular weight adiponectin and that of high-sensitivity troponin T were positively and independently associated with NT-proBNP. In addition, the HR-QOL score regarding sleep disorder was independently associated with NT-proBNP. Thus, we have obtained evidence that the plasma NT-proBNP is affected by several clinical variables in the general working population.

Nicorandil attenuates reperfusion injury after long cardioplegic arrest.

The cardioprotective efficacy of nicorandil in cardiac surgery was determined using a surgically relevant 4-hr cardioplegic arrest model. Each isolated rabbit heart was parabiotically blood-perfused using a modified Langendorff column. The magnitude of left ventricular developed pressure and rate of change of developed pressure over time were measured before (baseline) and after ischemia. Nicorandil was administered either pre-ischemia, post-ischemia, pre/post-ischemia, or continuously (before, during, and after ischemia). The endothelium of the coronary artery was observed by scanning electron microscopy. Serum myeloperoxidase activities were also measured. Although pretreatment with nicorandil did not affect recovery of developed pressure, administration of nicorandil after ischemia, or before and after ischemia, enhanced the recovery of developed pressure. Serum myeloperoxidase activity was decreased in the pre/post-ischemia and continuous groups. Endothelial reperfusion injury decreased in all nicorandil-treated groups. Administration of nicorandil attenuated ischemia-reperfusion injury of the myocardium and coronary endothelium while ameliorating leukocyte activation. In the event of unexpected prolonged cardioplegic arrest, administration of nicorandil, even just after declamping, may improve cardiac function. However, pre-ischemia administration alone was not helpful in the heart subjected to prolonged cardioplegic arrest.

Surgical repair for entire inferior vena cava occlusion in Budd-Chiari syndrome.

Successful repair of thrombotic occlusion of the entire inferior vena cava, including the iliac and hepatic veins, was performed on a 51-year-old man with Budd-Chiari syndrome associated with severe liver dysfunction.

Direct imaging of bileaflet mechanical valve behavior in the tricuspid position.

OBJECTIVE: The optimal orientation of a bileaflet mechanical valve for tricuspid valve replacement (TVR) has not yet been determined. The aim of this study was to use fiberoptic cardioscopy to evaluate the effect of orientation of a mechanical valve implanted in the tricuspid position on bileaflet mechanical valve behavior. METHODS: Twelve pigs (50-59 kg) underwent TVR with a St. Jude Mechanical Heart Valve (25 mm standard cuff model) after cardioplegic arrest. The mechanical valve was implanted horizontally in six pigs (Group H), and vertically in another six pigs (Group V). The heart was perfused with pellucid Krebs-Henseleit solution in situ and the mechanical valve behavior was observed with a fiberoptic endoscope during different heart rates (HRs) induced by ventricular pacing (60, 90, 120, 150 min(-1)). All images were recorded on a high-speed video system every 4 ms. The closing time lag (CTL) between the valve leaflets was calculated and compared between the two groups. RESULTS: In Group H, the lower valve leaflet tended to open incompletely and close earlier than the upper leaflet. The calculated CTL was 303+/-60 ms, 65+/-48 ms, 40+/-9 ms, and 40+/-26 ms at pacing HRs of 60, 90, 120, and 150 min(-1), respectively. In contrast to Group H, there was little difference in CTL between the right and left leaflets in Group V. The calculated CTL was 9+/-12 ms, 11+/-10 ms, 1+/-3 ms, and 6+/-7 ms at pacing HRs of 60, 90, 120, and 150 min(-1), respectively. There were significant differences in CLT between the two groups at each ventricular pacing rate (P < 0.01). CONCLUSIONS: Orientation of an implanted bileaflet valve in the tricuspid position significantly influenced leaflet motion. In a horizontal orientation, the lower valve leaflet opened incompletely and closed earlier than the upper leaflet. These results suggest that the gravity might affect leaflet motion and that bileaflet mechanical valves should be implanted vertically in TVR to prevent abnormal leaflet motion and thrombus formation.

Malignant fibrous histiocytoma of the trachea.

We experienced a rare case of malignant fibrous histiocytoma (MFH) arising in the trachea. A 24-year-old man with severe dyspnea had a well-defined mass in the cervical trachea on chest X-ray examination. Chest computed tomography showed a 2.0-cm diameter mass originating in the right-posterior wall of the trachea. The tumor occupied over 90% of the lumen. A radical excision of the tumor (tracheal resection) with tracheal plasty was performed. The microscopic diagnosis was MFH. The patient remains well, without evidence of recurrence, 3 months after surgery.

Lung adenocarcinoma can be subtyped according to tumor dimension by computed tomography mediastinal-window setting. Additional size criteria for clinical T1 adenocarcinoma.

OBJECTIVE: We sought to verify that the size of the solid component, which can be evaluated using the computed tomography mediastinal-window setting, provides new criteria for CT classification of lung adenocarcinoma. METHODS: Between 1994 and September 2002, we examined 60 patients who were clinically classified with stage T1 adenocarcinoma of the lung and normal serum CEA, who underwent standard surgical procedures. Tumor maximum dimension was evaluated using two different CT-imaging settings: the lung window (lDmax), and the mediastinal window (mDmax). We analyzed the relationships between prognosis or lymph node involvement and tumor dimensions. RESULTS: The mDmax was a significant (OR 1.11, P=0.02) predictive factor for lymph node metastasis. However, lDmax was not significant (P=0.83). Age, gender, lDmax, mDmax, and lymph node involvement were analyzed as predictive factors for prognosis. In univariate analysis, mDmax and lymph node involvement were significant predictive factors for prognosis (OR 1.07, P=0.01; OR 2.56, P=0.04; respectively). In multivariate analysis, mDmax was a significant predictive factor for prognosis (OR 1.06, P=0.04). We then classified the C-T1 adenocarcinoma patients into three groups according to mDmax: T1a (< or =10 mm), T1b (from 11 to 20 mm), and T1c (from 21 to 30 mm). There was a significant difference between the three groups: the disease-free 5-year survivals were 93.3, 58.1, and 32.7%, respectively (P=0.01). CONCLUSIONS: The mDmax can give additional, useful prognostic data. This finding may provide new criteria for CT classification of lung adenocarcinoma.

Heparinless cardiopulmonary bypass with argatroban in dogs.

OBJECTIVES: Systemic heparinization is usually required for cardiopulmonary bypass (CPB). However, problems such as heparin-induced thrombocytopenia, protamine shock, and antithrombin III deficiency exist related to CPB with heparinization. The aim of this study was to evaluate argatroban (ARG) as a substitute for heparin during CPB. METHODS: In the pilot study, blood samples were sequentially obtained from dogs with continuous infusion of ARG at a dose of 10 (n = 6), 20 (n = 6), or 30 (n = 6) microg/kg per min for 2 h without CPB. In the main study, dogs underwent CPB for 2 h with 10 (n = 6) or 30 (n = 6) microg/kg per min of ARG or with heparin with blood samples obtained sequentially. Thrombogenicity in each group was evaluated by observation of the blood-contacting surfaces of the CPB circuits with scanning electron microscopy (SEM). Evidence of thromboembolism in the dogs was also investigated in histological specimens of the kidney and spleen in addition to microscopic observation at autopsy. RESULTS: In the pilot study, the activated coagulation time (ACT) reached a maximum level dose-dependently after continuous infusion of ARG for 30 min. ACT returned to the baseline value within 60 min after the termination of continuous infusion. In the main study, CPB with 30 microg/kg per min of ARG achieved thrombin-antithrombin III complex (TAT) level similar to that achieved by CPB with heparin. Platelet count with 30 microg/kg per min of ARG tended to be higher than that with heparin or 10 microg/kg per min of ARG. The SEM appearance of blood-contacting surfaces of the CPB circuits after infusion with 30 microg/kg per min of ARG appeared to be similar to that after infusion with heparin. Depositions on the blood-contacting surfaces of the CPB circuits were also frequently observed with 10 microg/kg per min of ARG. CONCLUSIONS: Coagulability related to CPB was controlled by the appropriate ARG dosage without the use of heparin in dogs. ARG may be a substitute for heparin in CPB.

Predictive factors for survival in surgically resected clinical IA peripheral adenocarcinoma of the lung.

BACKGROUND: Patients with clinical IA (C-IA) lung cancer have a 5-year survival rate of approximately 70% after surgical therapy alone. We attempted to clarify preoperative factors that are predictive for poor prognosis after surgery among patients diagnosed with C-IA adenocarcinoma of the lung. METHODS: Between 1994 and April 2002, 65 patients with C-IA adenocarcinoma of the lung underwent lobectomy + hilar and mediastinal node dissection. The chest computed tomography (CT) imaging and clinicopathologic records of the patients were examined. Tumors were subtyped into solid type or nonsolid type categories according to the component of ground glass opacity assessed by CT. Age, sex, serum carcinoembryonic antigen (CEA) level, histologic subtype (replacing versus nonreplacing), and tumor size were also analyzed. RESULTS: Solid type on CT and high serum CEA level (>or=4.0 ng/mL) were prognostic factors for poor outcome in univariate analyses (p < 0.05). Solid type on CT, high serum CEA level, and larger tumor size (> 20 mm) were significant (p < 0.05) prognostic factors for poor outcome in multivariate analyses. Solid type on CT and high serum CEA level were significant (p < 0.01) risk factors for lymph node involvement in both univariate and multivariate analyses. Furthermore, based on the factors of CT subtype, tumor size, and serum CEA level, the 5-year disease-free survival rate was 20.1% for patients with two of the three factors, and 21.2% even if they were assessed as pN0. Computed tomography subtype was strongly associated with histologic subtype (p < 0.0001). CONCLUSIONS: Solid type on CT (associated with histologic subtype such as nonreplacing type), tumor size larger than 20 mm, and high serum CEA concentration are important preoperative predictive factors for poor outcome after surgery for patients with C-IA lung adenocarcinoma.

Carcinoembryonic antigen as a predictive factor for postoperative tumor relapse in early-stage lung adenocarcinoma.

OBJECTIVES: To clarify the usefulness of measuring serum carcinoembryonic antigen (CEA) preoperatively to detect patients who will have a poor outcome after surgery, and who cannot be selected by conventional staging modalities. METHODS: One hundred patients with adenocarcinoma of the lung underwent standard surgical procedures between 1994 and April 2001 at our institution. Preoperative staging was assessed according to the TNM classification of the International Union Against Cancer. The associations between preoperative serum CEA level and the postoperative recurrence or lymph node metastasis were examined. The serum CEA level was classified into two groups according to concentration of CEA level: low (normal) CEA (5.0 ng/ml). RESULTS: The high CEA level was associated with tumor relapse (P=0.01). According to the preoperative staging, the increased CEA was associated with tumor relapse only in stage C-IA (P=0.001). Stage C-IB and more advanced stages did not show an association between increased CEA and tumor relapse. In C-IA, risk for lymph node involvement was significantly higher in the high CEA group (4/9; 44.4%) than in the low CEA group (6/47; 12.8%, P=0.03). Furthermore, the rate of tumor relapse in C-IA-pN0 was significantly higher in the high CEA group (4 of the 5, 80%) than in the low CEA group (9 of the 41, 22.0%, P=0.018). The 5-year disease-free survival rate for patients with a high serum CEA level (N=9) was 22.2%, and 75.0% for patients with a normal CEA (N=47) level (P=0.0004). CONCLUSIONS: Increased serum CEA is an important predictive factor for poor outcome after surgery in early-stage (C-IA) lung adenocarcinoma.

Improved survival of surgery for acute type A aortic dissection: impact of noninvasive diagnosis and hemostatic surgical management.

OBJECTIVES: In the past decade, progress in cardiovascular technology has been incorporated into the surgical treatment of acute type A dissection resulting in remarkable improvement. Factors in this progress encompass rapid noninvasive diagnosis, intraoperative introduction of aprotinine, surgical glue, sealed grafts, and refined surgical technique. The objective of this study is to identify which factors contributed to the improvement of the surgical outcome of acute type A dissections. METHODS: Between January 1989 and February 2001, 78 consecutive patients had emergency surgeries for acute type A dissection. The initial 31 patients (group I) received preoperative angiography, when possible. Since 1996, the next 47 patients (group II) have received noninvasive rapid diagnosis with hemostatic surgical management. This included aggressive proximal resection and judicious use of gelatin resorcine formol glue and felt strips. Between the two groups, in-hospital mortality and morbidity, incidence of neurological complications, late survival and cardiovascular events were compared. Risk factors for in-hospital death were investigated with univariate and multivariate analysis. RESULTS: The in-hospital mortality was significantly improved in group II (4.3%) compared with group I (29.0%). Overall mortality was 14.1%. Multivariate analysis revealed preoperative limb ischemia and delayed timing of operation (> 3 hours after arrival) as independent risk factors for in-hospital death. Late survival at 5 years was 61.5+/-7.5%. Between the two groups there was no significant difference in late survival or cardiovascular events. CONCLUSIONS: Immediate surgical intervention, using rapid noninvasive diagnosis with hemostatic management, substantially improves the surgical outcome of acute aortic dissection.

Giant cell tumor of the rib.

We experienced a rare case of giant cell tumor (GCT) arising in the 5th rib involving the 5th vertebral body and transverse process. A 57-year-old man presented with a well-defined mass in the left thoracic cavity on chest x ray examination. Chest computed tomography showed a heterogeneous 7cm-diameter mass originating in the posterior segment of the left 5th rib. The tumor had spread to the 5th thoracic vertebra destroying the left half of the body and transverse process. Magnetic resonance imaging showed a heterogeneous-intensity mass involving the 4th to 6th ribs. A radical excision of the tumor followed by a 50 Gy radiotherapy was performed after embolization of the feeding arteries. The pathological diagnosis was a GCT. The patient remains well without evidence of recurrence for 6 years following surgery. The present case is only the 14th case of GCT arising in the rib to have been reported in Japan.

Coronary occlusion using bi-directionally stretched elastic sutures during off-pump coronary artery bypass grafting.

OBJECTIVE: Off-pump coronary artery bypass grafting may be partly invasive, particularly to the coronary endothelium that is snared. Efficacy of a simple technique to occlude a coronary artery with elastic sutures bi-directionally stretched just beneath the artery was evaluated. METHODS: Test subjects were eighteen adult mongrel dogs weighing 20-30 kg. After systemic heparinization (150 U/kg), the mid-left anterior descending artery (mid-LAD) was exposed with a stabilizer applied and snared using non-elastic sutures (n = 6) or elastic sutures (n = 6), or occluded with elastic sutures bi-directionally stretched (n = 6). The left internal thoracic artery (LITA) was anastomosed to the mid-LAD with humidified gas insufflation. After completion of the anastomosis, the mid-LAD was observed endoscopically through the LITA. The coronary endothelium was also observed by a scanning electron microscope (SEM) after perfusion fixation. RESULTS: Bleeding at the anastomotic site with the coronary artery occluded by bi-directionally stretched elastic sutures was observed. However, all anastomoses were done successfully with the aid of humidified gas insufflation. Coronary endoscope showed that the lumens snared with non-elastic sutures were collapsed with folds and often with clots. Coronary arteries snared with elastic sutures appeared similar to the arteries snared with non-elastic sutures endoscopically, but with less clots. In the case of coronary occlusion with bi-directionally stretched elastic sutures, the lumens were occluded in a flattened linear fashion without clots. SEM showed endothelial injuries with blood cells deposited when non-elastic sutures were used. When elastic sutures were used for snaring, endothelial injuries were ameliorated with less blood cells deposited, which were further decreased when elastic sutures were bi-directionally stretched. CONCLUSION: The coronary artery can be effectively occluded by bi-directionally stretched elastic sutures with minimal endothelial damage.

Successful management of acute pulmonary embolism after surgery for lung cancer.

OBJECTIVE: Although many case reports of acute pulmonary embolism (APE) have been published, the literature dealing with the management of APE after resection of lung cancer is limited. This report describes seven cases of successful management of APE after surgery for lung cancer and discusses how to manage this problematic complication. METHODS: The medical charts of seven patients with APE after lobectomy and complete mediastinal lymphnode dissection were retrospectively reviewed. RESULTS: Six patients collapsed during their first attempt at walking after surgery in conjunction with a dramatic respiratory change. All these patients promptly underwent enhanced spiral computed tomography (CT) scanning. Bilateral clots were detected in all patients and one patient with a deep venous thrombus (DVT) in the femoral vein had a temporary inferior vena cava filter implanted. Non-surgical therapy was used for six patients: thrombolysis (systemic urokinase) and anticoagulant (heparin or argatroban) for four patients and only anticoagulant therapy started on the day after the operation using argatroban for two. There were no bleeding problems with these thrombolysis and/or anticoagulant therapies except in one case of hemorrhage induced by heparin usage on the day after the operation. None of the cases required allotransfusion in connection with these therapies. Thromboembolectomy was performed for one patient who was hemodynamically unstable due to massive embolism and primary atrial fibrillation. All patients were discharged from our hospital without major complications. CONCLUSIONS: Patients with pulmonary embolism after surgery for lung cancer can be treated aggressively with anticoagulants with/without fibrinolitics or even with pulmonary embolectomy on cardiopulmonary bypass, without excessive risk of bleeding complications. Enhanced spiral CT scanning was very helpful for making a simultaneous diagnosis of APE and DVT. The use of argatroban in conjunction with activated clotting time monitoring should be effective without causing bleeding problems during the early stages after pulmonary resection for lung cancer.

Clinicopathological analysis of prognostic factors in clinical IA peripheral adenocarcinoma of the lung.

BACKGROUND: The clinical IA (C-IA) lung cancer patient shows a 5-year survival rate of approximately 70% after surgical therapy alone. We have tried to clarify the prognostic factors in C-IA adenocarcinoma of the lung to identify those candidates who might benefit from preoperative or postoperative adjuvant therapy. METHODS: Between 1994 and June 2001, 54 patients were diagnosed with C-IA adenocarcinoma of the lung and underwent lobectomy and hilar and mediastinal node dissection. The clinicopathological records of the patients were examined for age, gender, nodal status, tumor size, serum CEA level, and histologic subtype (replacing vs nonreplacing type). Localized bronchioloalveolar carcinoma (LBAC; noninvasive cancer) was excluded from this study. RESULTS: Nodal involvement, high serum CEA level (> or = 4.0 ng/mL), and nonreplacing type were significant (p < 0.05) prognostic factors for poor outcome in univariate analyses. Nodal involvement, larger tumor size (> or = 20 mm), and nonreplacing type were significant (p < 0.05) prognostic factors for poor outcome in multivariate analyses. High serum CEA level and nonreplacing type were significant (p < 0.01) risk factors for lymph node involvement both in univariate and multivariate analyses. Up to 71.5% of patients with both factors showed lymph node metastases. Furthermore, based on histologic subtype and tumor size, the 4-year survival rate was 33% for patients with both of these factors, and 34.3% even if they were pN0. CONCLUSIONS: C-IA patients, both with the larger tumor size (> or = 20 mm) and nonreplacing type, show poor outcome after surgery, and patients with both high serum CEA level and nonreplacing type are at high risk for lymph node metastases.

Lymph node metastasis, recurrence, and prognosis in small peripheral lung adenocarcinoma. Analysis based on replacement.

OBJECTIVE: We studied clinical and pathological features of small peripheral adenocarcinoma of the lung, focusing on tumor typing based on Noguchi's classification of small adenocarcinoma and determining whether these tumors grew by replacing alveolar lining cells. METHODS: Subjects were 51 patients with small peripheral adenocarcinoma 2 cm or less in diameter resected between 1994 and 2001. Mediastinal and hilar lymph node dissection was done in 37 (72.5%). Patients were divided into 2 groups by replacement or nonreplacement tumors. We compared patient profiles, lymph node involvement, and recurrence and survival patterns. RESULTS: No significant difference was seen between groups in mean age, surgical procedure, or primary tumor location. Women predominated in replacement tumors at 71% vs 41%, p = 0.04. The incidence of lymph node metastasis at 40% vs 4.5%, p = 0.007 and distant metastasis at 47% vs 2.9%, p < 0.001 was significantly higher in nonreplacement than replacement tumors. Replacements tumor thus showed significantly better disease-free survival at 95% vs 53%, p < 0.001, and overall 3-year survival at 95.4% vs 62.7% than did nonreplacement tumors. CONCLUSION: We found distant metastasis and lymph node involvement to be more frequent in nonreplacement than replacement small peripheral adenocarcinoma, on suggesting that pretreatment tumor typing and accurate nodal status determination are essential to improve disease staging.

Influence of St. Jude medical valve in patients with aortic stenosis and small aortic annulus on cardiac function and late survival result.

This clinical study analyzes our experience of postoperative cardiac function and long-term survival rate in patients with aortic stenosis and small-size St. Jude Medical (SJM) valve. Sixty-eight patients who underwent aortic valve replacement by SJM valve were divided into two groups by preoperative aortic annulus diameter. Group 1 consisted of 44 patients with small aortic annulus and small-size SJM valve (19 mm or 21 mm). In Group 1, small SJM standard valves were implanted in 16 patients, and small SJM Hemodynamic Plus (HP) valves were implanted in 28 patients. Group 2 consisted of 24 patients with large-size SJM standard valve (23 mm or larger). Preoperative left ventricular mass index, left ventricular dimension, the dimension of ascending aorta, and body surface area were significantly smaller in Group 1 than in Group 2. Average age at surgery was older in Group 1 than in Group 2. Effective orifice area index of the SJM valve measured by the manufacturer's data was smaller in Group 1 than in Group 2. Postoperative left ventricular mass indexes of Group 1 (standard valve or HP valve) and Group 2 significantly decreased in comparison with the preoperative mass indexes. Postoperative left ventricular ejection fraction and the peak ejection rate of Group 1 were not different from those of Group 2. The 10 year survival rate of Group 1 was 79%, and the rate of Group 2 was 77%. At 10 years after surgery, freedom from valve-related complication of Group 1 was 80%, and freedom from complication of Group 2 was 81%. Our results demonstrated that small-size SJM valve afforded satisfactory long-term survival rate and valve-related event-free rate for elderly patients with small body surface area and small aortic annulus.

Coronary arteriovenous fistula presenting as chronic pericardial effusion.

In August 1998, the patient, a 75-year-old woman, was diagnosed with pericardial effusion (PE) during an investigation of cardiomegaly. The PE disappeared after the administration of diuretics, but in February 1999, shortness of breath and general fatigue developed, and PE was again present. Diagnostic pericardiocentesis revealed bloody fluid. Chest computed tomography revealed a markedly expanded and tortuous right coronary artery (RCA). Coronary angiography (CAG) confirmed a RCA-coronary sinus fistula, and there was a significant step-up of O2 saturation at the right atrium. Cardiac tamponade developed soon after CAG, so the patient underwent surgical closure of the CAVF. Although a bleeding point was not identified, the PE was disappeared after operation. Histopathologically, parts of the wall of the fistula were quite thin and erythrocytes and lymphocytes had infiltrated the pericardial space. The clinical course and the findings indicate that the CAVF caused chronic PE.

Distensibility of the pulmonary autograft under systemic pressure.

BACKGROUND AND AIMS OF THE STUDY: Although the Ross procedure has recently been recognized as one of the best replacements of the aortic valve, regurgitation has occasionally been observed with dilatation of the sinotubular junction (STJ) and/or basal ring (BR). This study was designed to evaluate the native distensibility of the free pulmonary root under systemic pressure. METHODS: Pulmonary arterial grafts (n = 7) were taken from pig hearts and pressurized (20-100 cmH2O) with crystal sensors attached around the STJ and BR. Dimensions of the STJ and BR were measured using a digital 3-D ultrasonic sonomicrometer at different pressures (20-100 cmH2O) with and without the STJ and/or BR plicated with felt-strip to prevent overdistension. Valve insufficiency was evaluated macroscopically and endoscopically. RESULTS: All grafts showed no obvious valve insufficiency at 20 cmH2O. Grafts pressurized at 100 cmH2O showed 125+/-6% and 113+/-5% enlargement of dimensions compared with baseline (20 cmH2O) data at the STJ and BR respectively, with recognizable insufficiency. When the STJ was plicated to prevent overdistension at 100 cmH2O with less dilated BR (106%), mild excentric insufficiency was observed. In case of the BR plicated at 100 cmH2O with a less dilated STJ (112%), central slight regurgitation was observed. Both the STJ and BR plications resulted in no recognizable regurgitation. CONCLUSION: Free pulmonary arterial grafts were remarkably enlarged under systemic pressure with recognizable valve insufficiency; this could be prevented by maintaining the original dimensions of the graft STJ and BR.

Arterial embolization to preoperatively manage pulmonary disease associated with inflammation.

Preoperative arterial embolization is used in pulmonary disease to reduce intraoperative blood loss resulting from exposure of extensive adherent pleura due to repeated inflammation. Between January 1996 and February 2001, 5 patients underwent surgery with this procedure. Underlying diseases were 3 cases of aspergilloma and 1 each of chronic expanding hematoma and lung cancer. All embolization was permanent, involving coil insertion. Surgical treatment was successful in all 5 patients without mortality. Such preoperative management proved useful in reducing intraoperative blood loss in hypervascular collateral feeding vessels in the area of resection or decortication.

Geometrical difference between an ascending aneurysm and a root aneurysm in valve-sparing operations.

OBJECTIVE: The aortic root geometry of the leaflet size and coaptation in an ascending aortic aneurysm, and in a root aneurysm, may predict the early and late outcomes from valve-sparing surgery. METHODS: The aortic root was investigated using intraoperative endoscopy before and after valve-sparing root reconstruction. The definition of 'root aneurysm' was marked sinus dilatation proximal to the sinotubular junction. 'Ascending aneurysm' was defined as dominant dilatation distal from the sinotubular junction. Fifteen cases were examined and classified into two groups; Group A with an ascending aneurysm (four patients), and Group R with a root aneurysm (eleven patients). RESULTS: Cusp prolapse was seen in 10 (90.9%) patients of Group R, and in only one (25%) patient of Group A. The length of the free margin of all cusps in Group R was significantly longer than those in Group A. In Group R, the lengths of the free margin of an individual cusp were significantly different, indicating asymmetric cusps. In Group A, the length of the free margin were similar, indicating symmetric cusps. There was no significant difference in the degree of immediate postoperative aortic insufficiency, between the two groups. At the most recent follow-up, progressive aortic insufficiency was present in two patients of Group R. CONCLUSIONS: A root aneurysm had asymmetric, elongated and prolapsed aortic cusps, while an ascending aneurysm had symmetric cusps without prolapse. The mechanism of aortic insufficiency in a root aneurysm was more complex, suggesting a difficulty in achieving long-term valve competence. Such geometrical difference should be considered in the indication for the surgical technique of valve-sparing operations.