Protective effects of FK409, a novel nitric oxide donor, against postischemic myocardial dysfunction in guinea-pig hearts.

Effects of FK409 were investigated in perfused guinea-pig Langendorff hearts subjected to ischemia and reperfusion. Nitric oxide electrode, fluorometry, and 31P nuclear magnetic resonance imaging were used to monitor changes in cellular high-phosphorous energy and nitric oxide and Ca2+ content in the heart together with simultaneous recordings of left ventricular developed pressure. After cardioplegic arrest with St. Thomas' Hospital solution, normothermic (37 degrees C) global ischemia was induced for 40 min, and hearts were reperfused for 40 min. FK409 at 10(-8) M, which has a minimum inotropic effect on nonischemic hearts, was added to the cardioplegic solution. Treatment with FK409 reduced left ventricular developed pressure during and after ischemia and improved postischemic recovery of left ventricular developed pressure from 55.4% at 40 min of reperfusion in FK409-free hearts up to 80.4% in hearts treated with FK409 (p < 0.01). Flow rate at 1.5 min after treatment with the cardioplegic solution was 27.7 ml/min in hearts treated with FK409 compared with 21.2 ml/min in drug-free hearts (p < 0.01). Treatment with FK409 significantly effected preservation of tissue level of beta-adenosine triphosphate at the end of ischemia or reperfusion. During ischemia, arrested with the cardioplegic solution, intracellular Ca2+ accumulation and nitric oxide release were reduced. At the end of ischemia in FK409-treated hearts, nitric oxide release was 86% greater than in drug-free hearts without reference to the Ca2+ concentration. In cardiac surgery, normothermic arrested hearts are subject to damage by oxygen free radicals in reperfusion injury. Therefore, nitric oxide exogenously supplied by FK409 was responsible for the cardioprotective action, presumably by acting directly as an oxygen radical scavenger during reperfusion. A specific nitric oxide donor, like FK409, may have therapeutic use as a nitric oxide-mediated vasorelaxant and additional protective action for reperfusion-injury hearts.

[Surgical treatment for infective endocarditis with multiple embolic complications].

A 59-year-old man was transferred to our hospital because of severe right leg pain, dyspnea and anuria. Due to severe cyanosis of the legs below the knees and severe hyperkalemia, he had undergone embolectomy of the right femoral artery and hemodialysis. Medical treatment for infective endocarditis was started after the first operation, because transesophageal echo cardiography revealed severe aortic regurgitation and massive vegetation of the aortic valve. Amputation of the right leg below the knee and of the left leg below the Lisfranc joint was performed after 19 days and aortic valve replacement with patch closure of a perivalvular abscess was performed one month after the first operation. The post-operative course was uneventful. He was weaned from hemodialysis and the follow-up echocardiographic study revealed no vegetation.

[Catastrophic pulmonary vasoconstriction associated with protamine reversal of heparin].

Administration of protamine intravenously to neutralize the anticoagulant effects of heparin may be associated with hypotension. These adverse cardiovascular responses to protamine fall into three distinct types: transient hypotension related to rapid drug administration; anaphylactic responses: and catastrophic pulmonary vasoconstriction. We recently observed three patients who had catastrophic pulmonary vasoconstriction, which were treated with the assist circulation and intraaortic balloon pumping. The two patients were survived except one who was dead due to the cerebral ischemic damage which was introduced by delayed establishment of circulatory assist device. We conclude that meticulous longstanding observation of the hemodynamic condition is important after administration of protamine under the unremoved cannulations.

Tamponade after open-heart surgery with percutaneous cardiopulmonary support.

A 56-year-old man presented with late cardiac tamponade appearing on 9 postoperative day after weaning from percutaneous cardiopulmonary support. He had been referred to our hospital for congestive heart failure. He underwent aortic valve replacement and fell into postcardiotomy low output syndrome. He could not be weaned from extracorporeal circulation, and we had to use an intraaortic balloon pump and percutaneous cardiopulmonary support. On postoperative day 9, percutaneous cardiopulmonary support was successfully withdrawn without problems, but he showed signs of superior vena cava syndrome after the cannulas were removed. An echocardiogram also showed cardiac tamponade. When the wound was reopened, a lot of old clots had compressed the right atrium and, after clot removal, the patient's hemodynamic state improved markedly. It is important to be aware that percutaneous cardiopulmonary support may conceal hemodynamic deterioration due to cardiac tamponade and to take care that a patient does not experience hemodynamic deterioration after percutaneous cardiopulmonary support withdrawal.

[Two cases of coronary artery aneurysm including one case of the left main coronary artery aneurysm].

We report two cases of coronary artery aneurysm including one case of the left main coronary artery aneurysm. The coronary angiogram of one patient, a 68-year-old male, having anterior chest pain on exertion, revealed left anterior descending coronary artery (segment 6) aneurysm of 7 mm in diameter with 90% stenosis distal to the aneurysm and 75% stenosis in the right coronary artery (segment 2). The coronary angiogram of another patient, a 69-year-old female, having chest pain unrelated to exertion, revealed left main coronary artery aneurysm of 25 mm in diameter and delayed filling of contrast medium into the left anterior descending coronary artery. We decided to operate by the reason of not only significant coronary artery stenosis but risks of myocardial infarction due to embolization into distal coronary arteries and rupture of the aneurysm. We performed coronary artery bypass graftings using the great saphenous veins and closure of the coronary arteries running into and out the aneurysm under cardiopulmonary bypass. It is recommended that ligation of the coronary arteries connecting to the aneurysm or resection of the aneurysm followed by coronary artery bypass grafting is performed before developing myocardial infarction or rupture of aneurysm.

[A case of thymic cyst and thymoma with myasthenia gravis].

A case of 53-year-old male with thymic cyst was reported. We established diagnosis for myasthenia gravis. The chest CT and MRI demonstrated a cystic and mass lesion on the anterosuperior mediastinum. This finding suggested a thymic cyst and tumor with myasthenia gravis. The extended thymectomy was performed. Histological examination demonstrated the clear separation of the mixed type thymoma and the thymic cyst. The few reported cases of thymic cyst and thymoma with myasthenia gravis were reviewed.

Long term complete remission in primary plasma cell leukemia.

A 76-year-old female was diagnosed as having primary plasma cell leukemia (PCL), based on abundant atypical plasma cells in the circulation and bone marrow, monoclonal kappa light chain in the serum and urine, the immunophenotype of the plasma cells and the lack of preceding multiple myeloma. The patient was treated with melphalan and prednisolone (MP), and complete remission (CR) was achieved; this was maintained for 28 months. The duration of CR in this patient appears to be the longest of those reported in well-documented primary PCL patients who have been treated with MP chemotherapy.

[Atresia of the right coronary ostium associated with annulo-aortic ectasia--a case of successful surgical repair].

A case of a 51-year-old male with atresia of the right coronary artery and annulo-aortic ectasia is described. He presented with heart failure and underwent open-heart surgery. Preoperative aortography did not show the ostium of the right coronary artery. At surgery the right coronary ostium was not found on the intimal surface of the aneurismal aortic wall. A fine cord was attached to the adventitial surface of the anterior aortic root. A modified Bentall's procedure was performed to reconstruct the left coronary artery alone. The post-operative course was uneventful. It is speculated that the hypoplastic ostium of the right coronary artery was pulled up and formed a flap-like closure with increased expansion of the aorta.

Evaluation of intravascular hemolysis by haptoglobin administration after prosthetic valve replacement.

Although the measurement of serum haptoglobin (S-Hp) is of great use for evaluation of intravascular hemolysis, it is not applicable in patients with mechanical prosthetic valves because S-Hp is virtually absent. We administered haptoglobin preparation to 10 patients with Björk-Shiley mitral prosthetic valves and 10 patients with the same aortic prosthetic valves. Serum haptoglobin levels were measured periodically afterwards. The maximum haptoglobin levels (Hp (max)), serum, haptoglobin reducing rate ((Hp-delta Hp)/delta t) and expected haptoglobin disappearing time (hours) were obtained from the subsequent samples. The screening studies which were performed at the same time were not predictors of difference in the 2 groups. On the other hand, serum haptoglobin reducing rate and expected haptoglobin disappearing time indicated that hemolysis is higher in patients with an aortic prosthetic valve than with a mitral prosthetic valve. This haptoglobin administration test seems to be useful for the comparative examination of the intravascular hemolysis caused by the difference in the position of the prosthetic valve.

[Acute aortic dissection in a patient with Marfan's syndrome and severe pectus excavatum--emergency surgical repairs of ascending aortic dissection and aortic regurgitation complicated by pectus excavatum in Marfan's syndrome].

A case of acute aortic dissection Stanford Type A occurring in a patient with Marfan's syndrome, complicated with aortic regurgitation and severe pectus excavatum, is reported with successful surgical correction. The patient was a 33-year-old woman, who suffered from severe back pain riding to work. An emergency operation consisting of Cabrol's procedure for aortic dissection Stanford Type A and sternal turnover for pectus excavatum was performed simultaneously. Because of the postoperative mediastinal bleeding the implanted sterno-costal complex was removed on the second POD and the prosthetic sternum was reimplanted on the tenth POD. The two-stage operation seems preferable in such an emergency case to avoid postoperative bleeding and infection.

[A case of acute dissecting aneurysm associated with AAE (annuloaortic ectasia) necessitating coronary bypass surgery].

We report a successful surgical treatment of acute dissecting aneurysm of the ascending aorta associated with annuloaortic ectasia. The patient was a 29-year-old male, who was admitted to the hospital 5 hours after the onset of anterior chest pain. Aortography revealed acute dissection of the ascending aorta (DeBakery type I) with AAE. The intimal tear surrounding the right coronary ostium was found. The procedure between the right coronary artery and aorta (replaced artificial graft) using saphenous vein graft was also required in addition to Bentall's operation. Postoperative studies revealed disappearance of the dissection, patency of the bypass graft. The postoperative course was uneventful and the patient is in active life two years after operation.

[A case of quadricuspid aortic valve associated with coronary arterial legion].

A case of quadricuspid aortic valve is reported in a patient with coronary artery disease and abdominal aortic aneurysms. A 54-year-old male who had undergone aortic replacement because of abdominal aortic aneurysms three years before presentation was readmitted due to complaints of angina pectoris and palpitations. Aortography and coronary arteriography revealed severe aortic regurgitation and proximal occlusion of LAD and RCA. Surgical correction consisted of aortic valve replacement with a Björk-Shilely valve and coronary revascularization of LAD. During the operation, a quadricuspid aortic valve with one smaller and three larger cusps that showed mild myxomatous degeneration without dystrophic calcification and normal coronary arterial orifices were noted. Accordingly, severe aortic regurgitation may have resulted from the dysfunction of congenital malformed cusps and acquired sclerotic coronary disease was the main cause of the chest pain.

[Surgical repair of partial anomalous pulmonary venous connection to the coronary sinus--a case report of PAPVC with mitral and tricuspid valve regurgitation in adult].

We have recently performed a successful repair of a total right anomalous pulmonary venous connection to the coronary sinus associated with mitral and tricuspid regurgitation. A 54-year-old female was inaccurately diagnosed as atrial septal defect associated with mitral and tricuspid regurgitation preoperatively. Operation revealed that all the right pulmonary veins connected to the coronary sinus. Mitral regurgitation which might be caused by distortion of the anterior leaflet was repaired by McGoon's technique. A Carpentire-Edwards ring was employed for the tricuspid annuloplasty. Repair of the atrial septal defect was undertaken with a pericardial septation patch which was sutured in place. The roof of the coronary sinus was widened by cutback, so that blood from the pulmonary veins could drain into the left atrium. The postoperative course was uneventful, except for a supraventricular arrhythmia.

[One stage operation for annulo-aortic ectasia and pectus excavatum caused by Marfan's syndrome].

One stage operation was successfully performed on a 32-year-old man with annulo-aortic ectasia (AAE) and pectus excavatum caused by Marfan's syndrome. In the Bentall's operation for AAE, median sternotomy is usually carried out. In this case it was difficult to obtain a favorable viewing field due to an extremely deformed sternum and significant displacement of the heart into the left thoracic cavity. By removing the sternum en bloc, as a cost-sterno complex, the surgery was performed safely with an excellent operative field. In this surgery combined with the sternal turnover, the amount of intra and post operative bleeding was the same as occurs in other open heart surgeries.

[Replacement of superior vena cava with resection of Hodgkin's disease of the thymus: a case report].

A 31-year-old male was diagnosed to have malignant thymoma with superior vena cava occlusion. At operation, we performed extended resection of tumor and superior vena cava, and replacement with ringed PTFE graft. Histological diagnosis was nodular sclerotic type of Hodgkin's disease of thymus. He received radiation with Liniac and chemotherapy post operatively, and post operative venography revealed graft patent. He is doing well 3 years after surgery.

[A case of systemic origin of an aberrant artery to the basal segments of the left lung].

A thirteen-year-old asymptomatic boy was referred to our hospital because of a cardiac murmur detected on a routine physical examination at school. A plane chest radiography showed increased vascular markings in the left lower field. An Aortogram revealed a large artery arising from the descending aorta and suppling the left posterior basal segment which had no pulmonary arteries. A bronchogram showed no abnormal findings in the bronchial tree. A clinical diagnosis of systemic origin of an aberrant artery to the basal segments of the left lung was made, and left lower lobectomy was performed successfully. We discussed the difference of this anomaly from pulmonary sequestration as well as the surgical procedure.

Spontaneous coronary artery dissection with left ventricular aneurysm--a case report of successful surgical repair.

An aorto-coronary artery bypass operation combined with left ventricular aneurysmectomy was performed successfully in a 56-year-old man who had suffered spontaneous coronary artery dissection with left ventricular aneurysm. It is important to perform myocardial revascularization surgery even if the region for anastomosis is dissected.

[Spontaneous coronary artery dissection with left ventricular aneurysm--a case report of successful surgical repair].

Spontaneous coronary artery dissection is a rare entity. To our knowledge, 86 cases have been reported, and there are 7 operative treatment. The patient was 56 year-old male with a history of the previous myocardial infarction. A selective coronary angiography demonstrated marked dilatation of both coronary arteries. The thin radiolucent lines were shown within the LAD and first diagonal branch as a result of partial separation of the intima. A very large left ventricular myocardial aneurysm was also demonstrated within anteroapical walls, he underwent open heart surgery with left ventricular myocardial aneurysmectomy and aorto-first diagonal branch saphenous vein graft. This present case is the second report which describe a successful surgical treatment for the spontaneous coronary artery dissection with left ventricular aneurysm.

Usefulness of echocardiography in the long-term follow-up study after surgical treatment of annuloaortic ectasia.

From July, 1979 to August, 1987, 10 patients at our institution underwent a repair of annuloaortic ectasia (AAE), either with a separate aortic graft and valve or with Bentall's operation. There were no hospital deaths, although there were two late deaths from unrelated accidental causes. In nine of the patients, echocardiograms were recorded to evaluate the postoperative cardiac function and possible complications. M-mode echocardiography facilitated the evaluation of cardiac function, and two-dimensional echocardiography was better suited to studying the postoperative structures. On the other hand, the real time two-dimensional Doppler flow mapping ensured the diagnosis of dissecting aneurysms through the blood flow pattern. Although the postoperative hemodynamics improved significantly, pseudoaneurysms between the native aortic wall and the graft were detected in three patients, with compression to the composite conduit in one, and residual distal aortic dissection was noted in another three patients. It was thus concluded that the composite graft replacement of the ascending aorta and aortic valve in patients with AAE can be accomplished with a low risk, but pseudoaneurysm formation at the coronary ostial or aortic suture line may be observed late after surgery. Regular postoperative follow-up study is therefore of great importance, and echocardiography would be the most pertinent, non-invasive method of meeting this purpose.