Effects of atorvastatin on angiogenesis in hindlimb ischemia and endothelial progenitor cell formation in rats.

AIM: To investigate the mechanisms underlying the pro-angiogenic effects of statin, the effects of atorvastatin were investigated on the expression of angiogenic factors in ischemic hindlimbs of rats. The function and number of endothelial progenitor cells (EPCs) were investigated in hypertensive rats. METHODS: Hindlimb ischemia rats were administered 10 or 30 mg/kg/day atorvastatin orally for 2 weeks. Angiogenesis was evaluated by a laser Doppler and by Isolectin-B4 immunostaining. The expressions of VEGF, IL-8, angiopoietin (Ang)-1, Ang-2, eNOS, and hemoxidase (HO)-1 were evaluated by Western blotting and immunohistochemistry. Spontaneously hypertensive rats (SHR) were administered 10 mg/kg/day atorvastatin. EPC function was evaluated by colony formation and migration. The EPC number was evaluated by CD34-positive cells. RESULTS: A lowdose of atorvastatin, but not a highdose, significantly increased regional blood flow. Atorvastatin significantly increased the expressions of VEGF, IL-8, Ang-1, Ang-2, eNOS, and HO-1 proteins in ischemic hindlimbs. Atorvastatin significantly increased the number and colony formation of EPCs and decreased oxidation in mononuclear cells from SHR. CONCLUSION: Atorvastatin strongly induced angiogenesis with increases in angiogenic cytokines, HO-1 and EPC numbers. Statins are thus considered potertial agents for therapeutic angiogenesis.

Splenic artery aneurysm performed vascular reconstruction: a case report.

A 58-year-old man was found by abdominal echography to have a pancreatic cyst while undergoing a health examination. Later, a multidetector CT and enhanced CT revealed a splenic artery aneurysm. After consultation he was admitted to our hospital for surgery. Multislice CT and magnetic resonance angiography demonstrated a saccular aneurysm, 22 mm in size, located in the proximal portion of the splenic artery. It was resected, and the splenic artery was reconstructed by an end-to-end anastomosis. The patient's postoperative course was favorable, and, after improvement, he was discharged on the 7th postoperative day. As Doppler ultrasound echography is being increasingly used during health examinations, these lesions are being detected with greater frequency. When splenic artery aneurysms rupture, mortality rates increase; we must therefore avoid simplistic observations. There are various treatment strategies available, and we must select which one is appropriate on a case-by-case basis.

An impending rupture of a celiac artery aneurysm in a patient with Behçet's disease -- extra-anatomic aorto-common hepatic artery bypass: report of a case.

A celiac artery aneurysm associated with Behçet's disease is extremely rare. We herein present the case of successful surgical treatment for an impending rupture of a large celiac artery aneurysm with a wide proximal neck in a patient associated with Behçet's disease. To our knowledge, this is the first report of a procedure involving extra-anatomic aorto-common hepatic artery (CHA) bypass through the retroperitoneal space implanting a 6-mm expanded polytetrafluoroethylene graft. An 18-month postoperative magnetic resonance angiography scan showed a good patency of the aorto-CHA graft without an anastomotic pseudoaneurysm in a closure of aorta and anastomoses.

Vascular protecting effect of angiotensin receptor blocker (ARB) on the radial artery graft.

PURPOSE: We hypothesized that the vascular protecting effect of an angiotensin receptor blocker (ARB) reduced endothelial damage of the radial artery (RA) after coronary bypass and conducted a comparative study. PATIENTS AND METHODS: One hundred and sixty four patients were divided into the following two groups, Group C: 92 subjects who were orally administered Candesartan 8 mg/day, Group I: 72 subjects who were administered Imidapril at 5 mg/day. Graft angiography was performed one year after surgery and the RA intima was evaluated using an angioscope. RESULTS: Total cholesterol of Group C was 151.4+/-66.9 mg/dL, which was significantly lower than in Group I (182.2+/-27.8 mg/dL), and LDL cholesterol of the ARB-treated group, i.e., Group C was 96.1+/-32.5 mg/dL and significantly lower than in Group I (139.1+/-48.7 mg/dL). In angioscopy, yellow plaque was detected in the proximal RA in 7 (8.0%) and 8 (11.6%) patients of the Groups C and I, respectively, showing a lower tendency in the ARB-treated group. CONCLUSIONS: The results of evaluation one year after surgery revealed no significant difference in effects on the RA endothelium between ARB and ACE inhibitor. ARB reduced cholesterol and its effect was confirmed with blood examination data and endoscopic findings.

Estimation of cardiac function with rotary blood pump.

BACKGROUND: A rotary blood pump may be implanted as a bridge to cardiac transplantation. Also, mechanical, histological, and biochemical improvements have been described in cardiac function after the implantation of a left ventricular assists device (LVAD). Thus there is considerable enthusiasm that LVAD might be used as a bridge to the recovery of myocardial function. Unlike a pulsatile pump, however, we cannot stop the rotary blood pump to estimate cardiac function. If the rotary blood pump stops, back flow will occur. In this study, a new method was examined that can estimate cardiac function without stopping the pump. MATERIALS AND METHODS: Twelve pigs were subjected to this acute study. The pump was implanted as an LVAD with an inlet cannula inserted into the left ventricle and the outlet cannula into the ascending aorta. The assist ratio was changed to 75%, from 25%. The relationship between the dp/dt of the left ventricle pressure and the differentiated pump flow rate was examined. Also, cardiac function was changed by epinephrine loading to estimate this method under hyperdynamic heart conditions. RESULTS: There was high positive correlation between the dp/dt of left ventricle pressure and differentiated the pump flow rate to 75% assisted ratio, from 25%. This relationship was established under hyperdynamic conditions. CONCLUSION: This method is simple and useful for estimating the cardiac function without pump stoppage.

Staple line reinforcement with fleece-coated fibrin glue (TachoComb) after thoracoscopic bullectomy for the treatment of spontaneous pneumothorax.

BACKGROUND: We investigated the cause of pneumothorax recurrence after thoracoscopic surgery and the effectiveness of staple line reinforcement with fleece-coated fibrin glue (TachoComb) in the prevention of postoperative pneumothorax recurrence. METHODS: From April 3, 1992 to the end of December 2005, thoracoscopic bullectomy was performed on 499 patients of primary spontaneous pneumothorax. The causes of recurrence were investigated on 39 patients on the basis of surgical observations, preoperative chest computed tomography, and so on. The most common cause was new bulla formation (37 cases), 19 of which were apparently related to the staple line (within 1 cm of the staple lines) and 15 of which were not related to the staple line. After 2000, we stopped using forceps to grasp lungs and we have reinforced the staple line by applying fleece-coated fibrin glue. RESULTS: The staple line reinforced with fleece-coated fibrin glue, or sprayed with fibrin glue solution and the untreated group (bullectomy only with staples) were compared, and the recurrence rates were 1.22%, 7.25%, and 10.00%, respectively (P = 0.0006021). CONCLUSIONS: The recurrence rate after thoracoscopic bullectomy with fleece-coated fibrin glue was significantly lowered and we consider this procedure to be the treatment of choice for the management of spontaneous pneumothorax.

Surgery for ruptured abdominal aortic aneurysm with an aortocaval and iliac vein fistula.

The purpose of this study was evaluate the operative procedure and outcome of abdominal aortic aneurysm (AAA) patients with aortocaval fistula (ACF) and iliac vein fistula. From 1982 through 2004, we experienced five AAA patients associated with spontaneous aortocaval and aortoiliac venous fistula who underwent repair of AAA. Three patients were in hypovolemic shock, including one patient with cardiopulmonary arrest on admission who required cardiopulmonary resuscitation before surgery. These three ACF patients with hypovolemic shock underwent emergency operation and two patients with stable hemodynamic state underwent urgent operation. One of two ACF patients with stable condition was associated with unstable angina. One AAA patient with ACF-complicated angina underwent AAA repair with coronary artery bypass grafting; the remaining four patients underwent 3 bifurcated graft and 1 tube graft implantation. All surgical treatment of the fistula included direct closure within the aorta under digital compression in four patients and inferior vena cava clamp in one. The mortality rate was 25%. One ACF patient with retroperitoneal hematoma died of bleeding. Survival for ACF depends on early diagnosis and prompt surgical repair. Aortocaval fistula complicated with a rupture of aneurysm into retroperitoneal space had a severe fatal prognosis compared with uncomplicated ACF.

Child with fulminant myocarditis survived by ECMO Support--report of a child case.

A 6-year-old girl had cold-like symptoms. Administration of antibiotics did not improve the symptoms, and the patient had chronic chest pain. Electrocardiogram (ECG) demonstrated ventricular tachycardia (VT) and cardiac enzyme levels were increased. Mexiletine and olprinone were continuously administered, but slow VT and III degrees A-V block repeatedly occurred. Pulse therapy using methyl prednisolone was performed, but hemodynamics did not improve. Ejection fraction (EF) decreased to 20%, and metabolic acidosis occurred. Extra corporeal membrane oxygenation (ECMO) was applied 24 hours after admission to the intensive care unit (ICU). To apply ECMO, a median sternotomy was performed. An in-flow cannula (15 Fr) was inserted into the ascending aorta and an out-flow cannula (19 Fr) was inserted into the right atrium. After returning to the ICU, blood pressure (BP) were stable, and urine volume was maintained at about 100 ml/h. Methyl prednisolone and gamma-globulin were administered during circulatory assisted period. About 24 hours later, sinus rhythm was obtained, and weaning was started after improvement of the EF. BP was maintained at 100 mmHg with low dose catecholamine, which was weaned off 42 hours after commencement. Hemodynamics after this remained stable. EF improved to 54.2%. An ECG demonstrated right bundle branch block (RBBB) at the sinus rhythm. Severe inflammatory changes were pathologically observed, and we diagnosed myocarditis. The patient was discharged from the hospital on 43 days post admission, and currently attends school.

Late results of gelatin-resorcin-formalin glue-aided repair in acute type A aortic dissection.

Gelatin-resorcin-formalin (GRF) glue has been used to obliterate the false lumen of dissected aortas, resulting in reduced mortality. However, because of the cytotoxicity of formalin, the application of GRF remains controversial. In this study, a total of 138 consecutive patients with acute type A dissection since 1995, who underwent emergency graft replacement, were reviewed. The mean age was 65.5 years. The hospital mortality rate was 6.5%. In-hospital re-exploration rate and patency rate of the false lumen were 6.5% and 24.7%, respectively. The actuarial survival rates were 81.5% after 5 years and 54.8% after 10 years. Reoperation-free rates were 87.9% after 5 years and 72.3% after 10 years. Tissue necrosis or aneurismal degeneration was not demonstrated at reoperation. In conclusion, GRF glue demonstrats excellent tissue adhesion and hemostasis capability, and contributes to improve surgical results.

Validity of a limited ascending and hemiarch replacement for acute type A aortic dissection.

BACKGROUND: The extent of arch repair at emergency surgery for acute type A dissection is controversial. This study was designed to evaluate the rationale of tear-oriented conservative ascending/hemiarch replacement, comparing it against total arch replacement. METHODS: A total of 134 consecutive patients with acute type A dissection who underwent emergency surgery between 1995 and 2005 were reviewed. RESULTS: The median age was 68 years (range, 19 to 90); the patients were 62 men and 72 women. The extent of aortic resection included the ascending aorta and hemiarch in 105 patients (group AH) and the total aortic arch in 29 patients (group TA). The hospital mortality rates in groups AH and TA were 6.7% and 6.9%, respectively. The actuarial survival rates were 77.4% (AH) and 80.8% (TA) after 5 years, and 63.5% (AH) and 80.8% (TA) after 10 years. The freedom rates from reoperation were 91.3% (AH) and 88.0% (TA) after 5 years, and 60.9% (AH) and 76.6% (TA) after 10 years. Multivariate analysis indicated that predictors of reoperation were Marfan syndrome and aortic valve regurgitation. CONCLUSIONS: Limited ascending/hemiarch replacement did not increase the risk of reoperation and would not compromise late results.

Efficacy of low-dose continuous infusion of alpha-human atrial natriuretic peptide (hANP) during cardiac surgery: possibility of postoperative left ventricular remodeling effect.

BACKGROUND: The aim of the present study was to evaluate the efficacy of alpha-human atrial natriuretic peptide (hANP) in cardiac surgery under cardiopulmonary bypass (CPB). METHODS AND RESULTS: A prospective randomized study was conducted with 150 patients who underwent scheduled coronary artery bypass grafting to compare a group of patients receiving 0.02 microg x kg(-1) x min(-1) of hANP from the initiation of CPB with a group not receiving hANP. Hemodynamics, levels of atrial and brain natriuretic peptides (BNP), angiotensin-II and aldosterone, renin activity, and left ventricular (LV) function were examined. The hANP group showed significantly lower renin activity and lower levels of angiotensin-II and aldosterone during the early postoperative period, compared with the non-hANP group. The incidence of postoperative ventricular arrhythmia and the postoperative peak level of creatine kinase-MB were significantly lower in the hANP group. BNP at 1 month after surgery and measures of LV function were also significantly lower in the hANP group. CONCLUSIONS: Low-dose continuous infusion of hANP during cardiac surgery not only had a compensatory effect for the imperfections of CPB during the early postoperative period but also an inhibitory effect on postoperative LV remodeling and a reduction in ischemia/reperfusion injury. hANP should be part of the postoperative care for cardiac surgery.

40 Years experience in mitral valve replacement using Starr-Edwards, St. Jude Medical and ATS valves.

BACKGROUND: We have used the Starr-Edwards ball (S-E) valve since 1963, the St. Jude Medical (SJM) valve since 1978, and the ATS valve, since 1993 as the first choice of mechanical valve. In this study, the results with each valve during the 40 years were investigated in single mitral valve replacement (MVR) cases. PATIENTS AND METHODS: The mean age for S-E valves was 32.8+/-11.1 years old (y.o.), for SJM it was 47.2+/-12.6 y.o. and for ATS it was 56.3+/-11.4 y.o., indicating the aging of patients over time. The operative mortality decreased over the same time from 10.3% to 5.2% then 1.4% respectively. A significant difference was observed among the 3 groups with regards to the valve-related complication-free rate and cardiac event-free rate. However, there was no significant difference among the 3 groups with the other complications. CONCLUSION: Although there are many cases of valve-related complications with S-E valves, they have a role as an initial stage mechanical valve. In view of the long-term results extending over 20 years, the SJM valves is considered as the most reliable valve. The ATS valve is expected to achieve favorable results in the future because it may improve the quality of life (QOL) of patients and produce fewer valve-related complications.

Emergency surgery for acute type a aortic dissection in octogenarians.

BACKGROUND: Emergency surgery for acute type A dissection is associated with a high mortality rate in aged patients. This study was designed to explore perioperative risk factors and prognosis in octogenarians with acute type A aortic dissection. METHODS: Twenty-four octogenarians, of 134 consecutive patients with acute type A dissection between 1995 and 2005 who underwent emergency surgery, were reviewed. The median age was 82 years (80 to 90); the patients were 10 men and 14 women. All 24 patients underwent conservative tear-oriented surgery under deep hypothermic circulatory arrest with cerebral perfusion; the procedures were 23 ascending aortic replacements and one entire arch replacement. RESULTS: The hospital mortality rate was 13% (3 of 24 patients), without statistical significance compared with 6% in patients younger than 80 years. The late mortality rate was 38% (9 of 24 patients), with significance compared with 9% in the other patients. Five- and 10-year survivals ware 55% and 42%, respectively, compared with 83% and 73%, respectively (p = 0.0013), in the other patients. Univariate and multivariate analysis demonstrated that age 80 or greater was not an independent risk factor of hospital death. Risk factors of late death in younger-aged patients were pneumonia and reoperation. CONCLUSIONS: Emergency surgery for octogenarians with acute type A aortic dissection was successfully performed using a conservative intimal tear-oriented procedure, resulting in satisfactory early and late survival. Aggressive surgical treatment is mandatory for improving the outcome of this medical emergency in octogenarians.

Efficacy of continuous low-dose human atrial natriuretic peptide given from the beginning of cardiopulmonary bypass for thoracic aortic surgery.

PURPOSE: Cardiac surgery performed under cardiopulmonary bypass (CPB) causes abnormalities of the renin-angiotensin-aldosterone system, resulting in decreased urine output and an accumulation of water in the third space. We studied the efficacy of continuous low-dose human atrial natriuretic peptide (hANP) in patients undergoing thoracic aortic surgery. METHODS: We divided 40 patients undergoing thoracic aortic surgery into two groups: the hANP group, which received 0.02 microg/kg per minute of hANP and the non-hANP group, which did not. The hemodynamics, urine output, intensive care unit (ICU) and hospital stay, bleeding volume, homologous blood transfusion volume, furosemide dose, corrected KCl volume, and postoperative respiratory, hepatic, and renal function were compared in the two groups. RESULTS: The urine output during CPB and from CPB weaning to return to ICU was significantly better in the hANP group. The bleeding volume, homologous blood transfusion volume, furosemide dose, and corrected KCl volume were all significantly less in the hANP group. CONCLUSIONS: These findings support the consensus that hANP exerts its diuretic effects to their full potential when administered continuously at low doses during thoracic aortic surgery. We found it to be effective for postoperative hemostasis and for preventing ischemic reperfusion injury.

Outcome of emergency conventional coronary surgery for acute coronary syndrome due to left main coronary disease.

BACKGROUND: Outcomes of emergency coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) due to left main coronary (LMT) disease remain unclear. This study aimed to assess prognoses for patients undergoing emergency CABG for ACS due to LMT disease. METHODS: One hundred and four patients undergoing emergency CABG for ACS due to LMT disease were retrospectively reviewed. All patients had intra-aortic balloon pumping (IABP) support and underwent surgery within 48 hours after onset. We determined predictors for operative mortality and calculated cardiac event free, actuarial survival, and cumulative graft patency rates. RESULTS: We found that 9 patients (8.7%) developed pre-operative cardiogenic shock and 7 of them required percutaneous cardiopulmonary support (PCPS). Operative mortality affected 9 patients (8.7%). Cardiac event free rate and actuarial survival rate at 10 years were 80.7 and 75.4%, respectively. Logistic regression analysis showed that pre-operative cardiogenic shock was the only predictor for operative mortality (p = 0.0146, odds 5.96). Cumulative graft patency rates for internal thoracic artery and saphenous vein (SVG) at 5 years were 92.6 and 72.4%, respectively. One year-graft patency rate for the radial artery (RA) was 100%. CONCLUSION: It is still very hard to treat patients with cardiogenic shock. We suggest that immediate percutaneous coronary intervention (PCI) with mechanical supports is required prior to CABG for survival of patients with left main shock syndrome.

A successfully operated case of prosthetic valve thrombosis during planned pregnancy.

The patient was a 29-year-old woman who, when she was an 8-year-old, had undergone atrial septal defect (ASD) closure and mitral valve replacement (MVR) using a Björk-Shiley valve (25 mm) for Lutembacher syndrome. Because of a planned pregnancy, warfarin had been replaced by heparin. During the 7th week of pregnancy, she was admitted to our hospital because of dyspnea. She was diagnosed with acute heart failure due to prosthetic valve thrombosis. Following termination of pregnancy, the mitral valve was replaced with an ATS valve (25 mm). She was discharged 10 days after surgery without complications.

The possibility of a veno-arterial bypass system using the Abiomed BVS 5000.

Effect of Abiomed BVS 5000 (Cardiovascular Inc., Danvers, MA, U.S.A) has been reported for mechanical assist circulation in cardiogenic shock. However, this pump is generally used as a ventricular assist device, not as a device for veno-arterial bypass. Therefore, we evaluated its effectiveness through an experiment. The left anterior descending branch of pigs' heart was ligated to prepare a model of acute myocardial infarction, and after the onset of cardiogenic shock, circulation was initially supported for 30 min using the BVS 5000, followed by support for another 30 min using a Gyro pump (Gyro, Kyocera, Inc., Kyoto, Japan). Subsequently, circulation was additionally supported for 30 min using both a Gyro and an intra-aortic balloon pump (IABP) (Tokai Medical Inc., Aichi, Japan) (Gyro + IABP). Circulation was supported in each group at 30-min intervals in the reversed order of assisted circulation. Although the mean aortic pressure, pump flow, and total flow were not significantly different among the three setups, the pulse pressure was 48.2 +/- 3.3, 12.2 +/- 2.2, and 29.9 +/- 3.8 mm Hg in Abiomed, Gyro, and Gyro + IABP, respectively. Although neither coronary arterial nor myocardial blood flow showed significant differences among the three setups, the renal arterial blood flow was significantly larger in BVS 5000 compared to the other two setups. In this study, we selected an alpha-cube (Platium Cube NCVC 6000, Edwards Research Medical Inc., Salt Lake City, UT, U.S.A.), which is considered as an oxygenator that produces minimum pressure loss. Therefore, the pulsatile flow we obtained with the Abiomed was maintained even after we started using the oxygenator. The pulsatile flow had positive effects on renal circulation and peripheral circulation.

Efficacy of a proton pump inhibitor given in the early postoperative period to relieve symptoms of hiatal hernia after open heart surgery.

PURPOSE: To evaluate the efficacy of a proton pump inhibitor, we retrospectively reviewed patients who underwent gastric fiberscopy (GFS) in the early phase after cardiac surgery. METHODS: The subjects were 103 patients who underwent GFS for poor appetite, gastric pain, heartburn, or hematemesis after cardiac surgery. We divided the patients into two groups: group I consisted of 49 patients who received an H2-receptor antagonist (ranitidine hydrochloride 300 mg/day), and group II consisted of 54 patients who received a proton pump inhibitor (PPI; sodium rabeprazole 10 mg/day) as prophylactic treatment. The incidence of upper gastrointestinal (GI) disease was compared in the two groups. RESULTS: Gastric fiberscopy confirmed that 82.5% of the patients had type I hiatal hernia. The incidences of gastric pain and heartburn were significantly higher in group I (12.2% and 83.7%) than in group II (0% and 37.0%). Moreover, gastric bleeding occurred in two patients from group I, one [corrected] of whom died of coagulopathy. The incidences of hemorrhagic gastritis, active ulcer, and reflux esophagitis were significantly higher in group I than in group II, at 22.4%, 22.4%, and 24.5% vs 1.9%, 0%, and 7.4%. CONCLUSIONS: Early postcardiotomy GFS confirmed a high incidence of type I hiatal hernia. However, the proton pump inhibitor given in the early postoperative period proved more effective than the H2-receptor antagonist for relieving GI symptoms and preventing upper GI disorders after cardiac surgery.

[Two cases of postoperative local skin recurrence of breast cancer successfully treated with chemotherapy of irinotecan hydrochloride (CPT-11)].

Breast cancer is a neoplasm which is considered well-responsive to chemotherapy, radiation therapy and endocrine therapy. However, recurrent breast cancer will grow developing a tolerance to the variety of therapies. We reported two cases of recurrent breast cancer which showed a good response to CPT-11. These tumors were already refractory to anthracycline and taxanes. A weekly CPT-11 infusion therapy was effective to the recurrent skin and soft tissue lesions (CR and PR), and the tumor markers (CEA and CA15-3) markedly declined. CPT-11 is a useful treatment for multiple drug resistant recurrent breast cancer.