Good syndrome with thymic adenosquamous carcinoma--report of a case.

A 68-year-old man with recurrent bilateral severe pneumonia and invasive thymic carcinoma was admitted to our hospital. An extended thymo-thymectomy with lymph nodes dissection was performed for an irregular shaped anterior mediastinum mass. The tumor was mainly composed of type C, adenosquamous carcinoma, and found to have a small area of types B2 and B3 thymoma. History and laboratory findings were compatible with the diagnosis of Good syndrome. Although there are some reports of thymic carcinoma arising from thymoma, this is the first report of co-existence of adenosquamous carcinomas and thymoma with Good syndrome as far as reviewed articles. Thymic carcinoma with severe infection should be examined carefully for co-existence of thymoma, and co-existence of thymoma and thymic carcinoma suggests a close histogenetic relationship between the 2 tumors.

The fundamental properties of Homer 1 in association with cardiac ryanodine receptor in mouse heart.

BACKGROUND: Homer, known as a scaffolding protein that regulates postsynapse signaling in neurons, has been poorly explored in cardiac research. We show the fundamental properties of Homer 1 in mouse heart in association with cardiac ryanodine receptor (RyR), a binding protein of Homer 1. METHODS AND RESULTS: Immunohistochemistry of adult mouse heart with Homer 1 antibody showed striated staining on Z-bands both in atria and ventricles. The interactions between Homer 1 and RyR were confirmed by co-immunoprecipitation assays. Immunostaining of adult isolated cardiomyocytes showed partial co-localization of both proteins. In neonatal primary cultures, targeting of Homer 1 preceded that of RyR in their Z-band arrangement. CONCLUSIONS: Homer 1 binds to RyR in adult mouse heart and precedes RyR in Z-band arrangement in the early postnatal period.

Cytosolic phospholipase A2 inhibition attenuates ischemia-reperfusion injury in an isolated rat lung model.

BACKGROUND: Arachidonic acid metabolites and platelet-activating factor (PAF) are potentially involved in ischemia-reperfusion (IR) lung injury. A key enzyme regulating their metabolism is cytosolic phospholipase A2 (cPLA2). Arachidonyl trifluoromethyl ketone (AACOCF3) is reported to be a potent cPLA2 inhibitor. In the present study, we hypothesized that pharmacological inhibition of cPLA2 might ameliorate IR lung injury. METHODS: To test the hypothesis, we examined the effects of AACOCF3 in an isolated rat lung model. Three groups were defined (n=6, each): in the vehicle group, lungs were perfused for 2 hours without an ischemic period. In the ischemic groups, 20 mg/kg of AACOCF3 (AACOCF3 group) or saline (control group) was i.v. administered 15 min before lung harvest. Lungs were flushed with LPD solution, cold-stored 18 hours, and reperfused for 2 hours. RESULTS: IR increased cPLA2 activity mainly via alveolar macrophages, sPLA2 activity, thromboxane and leukotriene formation, and the expression of PAF receptor, whereas AACOCF3 treatment significantly reduced all of these. Compared to the vehicle group, the wet-to-dry ratio, proteins in BAL, and MPO activity increased significantly by twofold, fourfold, and threefold, respectively. Furthermore, the PO2 dropped from 615.7+/-31.2 to 452.1+/-30.9 mmHg at the end of reperfusion (P<0.001). AACOCF3 treatment maintained the PO2 at a level similar to the vehicle group throughout reperfusion and reduced significantly the alveolar-capillary leakage, edema formation, and neutrophil extravasation. CONCLUSION: Pharmacological inhibition of the cPLA2 cascade decreases bioactive lipid formation and attenuates IR-induced lung injury.

Critical role of cyclin D1 nuclear import in cardiomyocyte proliferation.

Mammalian cardiomyocytes irreversibly lose their capacity to proliferate soon after birth, yet the underlying mechanisms have been unclear. Cyclin D1 and its partner, cyclin-dependent kinase 4 (CDK4), are important for promoting the G1-to-S phase progression via phosphorylation of the retinoblastoma (Rb) protein. Mitogenic stimulation induces hypertrophic cell growth and upregulates expression of cyclin D1 in postmitotic cardiomyocytes. In the present study, we show that, in neonatal rat cardiomyocytes, D-type cyclins and CDK4 were predominantly cytoplasmic, whereas Rb remained in an underphosphorylated state. Ectopically expressed cyclin D1 localized in the nucleus of fetal but not neonatal cardiomyocytes. To target cyclin D1 to the nucleus efficiently, we constructed a variant of cyclin D1 (D1NLS), which directly linked to nuclear localization signals (NLSs). Coinfection of recombinant adenoviruses expressing D1NLS and CDK4 induced Rb phosphorylation and CDK2 kinase activity. Furthermore, D1NLS/CDK4 was sufficient to promote the reentry into the cell cycle, leading to cell division. The number of cardiomyocytes coinfected with these viruses increased 3-fold 5 days after infection. Finally, D1NLS/CDK4 promoted cell cycle reentry of cardiomyocytes in adult hearts injected with these viruses, evaluated by the expression of Ki-67, which is expressed in proliferating cells in all phases of the cell cycle, and BrdU incorporation. Thus, postmitotic cardiomyocytes have the potential to proliferate provided that cyclin D1/CDK4 accumulate in the nucleus, and the prevention of their nuclear import plays a critical role as a physical barrier to prevent cardiomyocyte proliferation. Our results provide new insights into the development of therapeutics strategies to induce regeneration of cardiomyocytes. The full text of this article is available at http://www.circresaha.org.

Estrogen inhibits cell proliferation through in situ production in human thymoma.

PURPOSE: We showed previously estrogen receptor (ER) alpha as an independent prognostic marker in human thymoma. Estrogen sulfotransferase (EST), steroid sulfatase (STS), 17beta-hydroxysteroid dehydrogenase (17beta-HSD), and aromatase are considered to play important roles in hormone metabolism of estrogen-dependent tumors. EXPERIMENTAL DESIGN: We examined estrogen production using primary cultures of human thymoma epithelial cells (TEC), intratumoral estradiol (E(2)) concentrations, and status of these enzymes above using immunohistochemistry or semiquantitative reverse transcription-PCR. We then correlated these findings with clinicopathologic variables and/or clinical outcome in 132 patients. RESULTS: E(2) inhibited cell proliferation via ERalpha in TEC, which synthesized estrone and E(2). Intratumoral E(2) concentrations were inversely correlated with EST, positively correlated with STS or 17beta-HSD type 1, and significantly higher in lower-grade or early-stage thymoma. EST status was positively correlated with tumor size, clinical stage, histologic differentiation, and Ki-67 labeling index and significantly associated with adverse clinical outcome and turned out to be a potent independent prognostic factor. STS and/or 17beta-HSD type 1 status was inversely correlated with Ki-67 labeling index and associated with lower histologic grade or early clinical stages. CONCLUSIONS: E(2) inhibits proliferation of TEC through ERalpha, which suggests that E(2) may be effective in treatment of thymoma, especially inoperable tumor, possibly through suppressing its cell proliferation activity. EST status is a potent prognostic factor in thymoma through inactivating estrogens. In situ estrogen synthesis through intracrine mechanism therefore may play important roles in tumorigenesis and/or development of thymoma through regulation of cell proliferation in an intracrine manner.

MCI-186 (edaravone), a free radical scavenger, attenuates ischemia-reperfusion injury and activation of phospholipase A(2) in an isolated rat lung model after 18 h of cold preservation.

OBJECTIVE: Increased microvascular permeability and extravasation of inflammatory cells are key events in ischemia-reperfusion (IR) injury. We hypothesized that edaravone, a free radical scavenger, is able to attenuate IR lung injury by decreasing oxidative stress and phospholipase A(2) (PLA(2)) activation, which otherwise may lead to lung injury through PAF receptor (PAF-R) activation. METHODS: We used an isolated rat lung model. Five groups were defined (n=7, each): in the sham and vehicle group, lungs were immediately washed after thoracotomy or perfused for 2h without an ischemic period, respectively. In the ischemic groups, 10mg/kg of MCI-186 (edavorane group), 1mg/kg of PAF-R inhibitor (ABT-491 group) or saline (control group) were i.v. administered 20 min before harvest. Lungs were flushed with LPD solution, stored at 4 degrees C for 18 h, and reperfused for 2h. RESULTS: Compared to vehicle group, IR significantly decreased the PO(2) level and increased the wet-to-dry ratio, proteins in bronchoalveolar lavage (BAL), and myeloperoxidase (MPO) activity in the control group, while edaravone treatment maintained the PO(2) similar to the vehicle group and significantly reduced edema formation and neutrophil extravasation. Consistently, IR significantly increased lipid peroxidation, cytosolic-PLA(2) activity mainly via alveolar macrophages, soluble-PLA(2) activity, leukotriene B(4), and PAF-R expression in control lungs, together with a decreased PAF acetylhydrolase (PAF-AH) activity. Edaravone significantly reduced all of these, but increased PAF-AH activity. Furthermore, pharmacological inhibition of the PAF-R attenuated IR injury resembling edaravone action. CONCLUSION: Edaravone attenuates lung IR injury by suppressing oxidative damage and PLA(2) activation, which otherwise partially mediates edema formation and neutrophil extravasation through PAF-R activation.

Skeletonized harvesting improves the early-term and mid-term perfect patency of a radial artery graft.

OBJECTIVE: A radial artery (RA) graft is frequently used for coronary artery bypass grafting (CABG), but little information exists regarding the early- and mid-term patency associated with the harvesting procedure. The objective of this study is to compare the early- and mid-term patency of the RA graft obtained using non-skeletonized and skeletonized harvesting. METHODS: Altogether, 131 patients and 159 anastomoses were studied. In 85 patients the RA was harvested non-skeletonized (group A: procedures between September 2000 and November 2002), whereas in 46 patients the RA was harvested skeletonized (group B: procedures between November 2002 and April 2004). Angiography results were analyzed before discharge [A: postoperative day (POD) 14.7 +/- 2.9, 75 patients, 90 anastomoses; B: POD 13.7 +/- 1.9, 38 patients, 47 anastomoses], and after 1 year (A: POD 386.8 +/- 149.3, 44 patients, 51 anastomoses; B: POD 267.1 +/- 148.7, 11 patients, 13 anastomoses). RESULTS: There was no difference in patency between the two groups (group A vs group B, 96.7% vs 100%, P = not significant [NS], in the early-term, 96.2% vs 100%, P = NS, in the mid-term). However, the perfect patency rates for groups A and B were 86.7% and 98.1%, respectively, in the early-term (P = 0.034) and 77.5% and 100%, respectively, in the mid-term (P = 0.048). The location and severity of the target vessel did not influence the angiographic results. CONCLUSION: The early- and mid-term patency of RA grafts was excellent, and skeletonized harvesting improved the perfect patency rates at both time points.

Physiological comparison of off-pump and on-pump coronary artery bypass grafting in patients on chronic hemodialysis.

OBJECTIVES: Despite the long-term benefit, the operative results of conventional coronary artery bypass grafting for chronic hemodialysis patients remain unsatisfactory. The efficacy of off-pump coronary artery bypass grafting for hemodialysis patients is yet to be determined. The purpose of this study was to investigate the postoperative physiology of off-pump coronary artery bypass grafting for hemodialysis patients. METHODS: Twenty-five hemodialysis cases who underwent isolated coronary artery bypass grafting were reviewed. Fifteen of these patients underwent off-pump coronary artery bypass grafting (off-group) and 10 underwent on-pump coronary artery bypass grafting (on-group). Comparisons were made in cardiac function (cardiac index and stroke volume index), respiratory function (AaDO2), hemodialysis management (blood urea nitrogen, creatinine, right atrial pressure, pulmonary wedge pressure), and bleeding tendency (postoperative blood loss and blood transfusion). RESULTS: There was no operative mortality, but 3 major postoperative complications occurred (2 sternal wound infections in the off-group and 1 pneumonia in the on-group). There was no difference in cardiac index or stroke volume index. AaDO2 was significantly lower in the off-group. Plasma concentrations of blood urea nitrogen and creatinine were similar between groups. Right atrial pressure was lower and pulmonary wedge pressure tended to be lower in the off-group. Postoperative bleeding and blood transfusion were similar between groups. CONCLUSION: Our study confirmed that off-pump coronary artery bypass grafting is feasible for hemodialysis patients. Physiologic data showed that off-pump coronary artery bypass grafting might be effective in preserving postoperative lung oxygenation.

[Endoscopic radial artery harvesting].

The radial artery is a popular arterial conduit for coronary artery bypass grafting (CABG). However, the traditional open harvesting technique requires a long incision, and is therefore associated with some wound complications and cosmetic problems. In order to solve them, we introduced the endoscopic radial artery harvesting (ERAH) at our institution in February 2004 utilizing the VasoView system. The ERAH technique was performed as safely as the traditional open technique and the harvested radial arteries were acceptable as CABG conduits. In particular, patients are satisfied with the excellent cosmetic results of the procedure. Herein, we focus surgical technique, complications of ERAH and ways to prevent them by describing our initial experience and short-term clinical follow-up of the ERAH patients.

Aprotinin attenuated ischemia-reperfusion injury in an isolated rat lung model after 18-hours preservation.

OBJECTIVE: Ischemia-reperfusion injury is a major factor in the early phase of lung transplantation. We hypothesized that aprotinin, a nonspecific serine protease inhibitor, attenuates ischemia-reperfusion lung injury by inhibiting the inflammatory response and suppressing NADPH oxidase. METHODS: We used an isolated rat lung model to test the above. A Control group was immediately perfused with fresh heparinized allogeneic blood after lung harvest without an ischemic period. Study lungs were flushed with low-potassium dextran (LPD) solution and stored for 18h at 4 degrees C then divided into two groups: the LPD group was flushed with LPD solution only, and the LPD+A group was flushed with LPD solution +200KIU/ml aprotinin. Lungs in all three groups were then reperfused with fresh heparinized allogeneic blood for 120min at 37 degrees C. RESULTS: Throughout reperfusion, PO(2) levels in the LPD+A group were similar to those in the Control group; although in the LPD group, PO(2) levels were significantly lower (P<0.05). Tissue MDA levels were significantly higher in the LPD group than the Control and LPD+A groups (P<0.05). IL-8 levels were significantly higher in the LPD group than the Control group (P<0.05), while in the LPD+A group they were similar to those in the Control group. Histological evaluation showed interstitial edema accompanied by neutrophil extravasation in the LPD group, whereas this effect was modest in the LPD+A group. An additional study of ischemia-reperfusion in an alveolar macrophage culture showed that the activitvation of NADPH oxidase, and translocation of p47(phox) from the cytosol to the membrane were suppressed in aprotinin group. CONCLUSIONS: Aprotinin attenuates ischemia-reperfusion lung injury by inhibiting the early inflammatory response, neutrophil extravasation and the production of oxygen free radicals through inhibition of the activation of the NADPH oxidase. The inhibition of p47(phox) translocation in alveolar macrophage seemed involved in this mechanism of aprotinin.

Endoscopic radial artery harvesting: our initial experience and results of the first 25 patients.

BACKGROUND: The radial artery has become an increasingly popular arterial conduit for coronary artery bypass grafting (CABG). However, the traditional open harvesting technique requires a long incision, and is therefore associated with some wound complications and cosmetic problems. Here, we describe our experience of endoscopic radial artery harvesting (ERAH) through a small incision in 25 patients who underwent CABG. MATERIALS AND METHODS: Between February 2, 2004 and January 7, 2005, a total of 25 patients (4 females; mean age: 64+/-10 years) underwent ERAH using the VasoView System (Guidant Corporation, Indianapolis, IN) at our institution. All patients underwent a preoperative Allen test to assess the competence of the palmer arch. Twenty-four radial arteries were harvested from the nondominant arm and one from the dominant arm. The mean clinical follow-up was 8+/-2.9 months. RESULTS: All radial arteries were harvested through a 2-cm incision at the wrist, successfully removed with ERAH and successfully used as CABG conduits. The mean harvest time was 59+/-11 min, and the mean harvested length was 17+/-1.7 cm. No adjunctive procedures were required during vessel harvesting, and no conversions to the open technique were necessary. Harvesting complications included 2 cases of postoperative hematoma and 7 cases of superficial radial nerve paresthesia. Five postoperative angiographies were performed and all radial arteries were patent. Overall, 24/25 (96%) patients were satisfied with the procedure. CONCLUSION: The ERAH technique was performed as safely as the traditional open technique and the harvested radial arteries were acceptable as CABG conduits. In particular, patient satisfaction with the procedure regarding the cosmetic results was excellent.

Hand circulation after radial artery harvest for coronary artery bypass grafting.

Despite wide spread use of the radial artery (RA) graft for coronary artery bypass grafting, the change of hand circulation after RA harvest has not been fully clarified. Severe hand ischemia such as resting pain or gangrene is a rare complication and has been reported in 4 patients. These cases resulted from occlusive artery disease in forearm, which should be carefully explored before RA harvest. Incidence of mild hand ischemia such as hand claudication or fatigue is unknown, but our study suggested that around 10% of the patients developed mild hand ischemia after RA harvest. The blood flow to the forearm territory was decreased by 20% after RA harvest despite the compensatory dilatation of ulnar artery. The presence of low perfusion in the affected hand has been pointed out in some studies. We reported the decreased tissue oxygenation of the affected hand during hand grip exercise. The Allen test is the most popular preoperative screening method, but is associated with considerable numbers of false-positive and false-negative results. Full length scanning of ulnar artery by ultrasonography seems to have a lower false-positive rate. But further clinical experience is necessary to establish a more reliable screening method.

Oral cibenzoline reduces postoperative atrial fibrillation in coronary artery bypass grafting.

OBJECTIVE: The objective of the present study was to investigate the effectiveness of postoperative oral administration of cibenzoline for the prevention of atrial fibrillation (AF) in coronary artery bypass grafting (CABG). METHODS: A total of 39 patients who underwent isolated CABG from September 2000 to February 2001 and who took oral cibenzoline (300 mg per day for 10 days beginning immediately after surgery) were compared to 59 patients who underwent surgery in our department 8 months prior to the study and who did not take cibenzoline for incidence of postoperative AF. Exclusion criteria encompassed age (>80 years), low ejection fraction (<30%), high serum creatinine level (>2.0 mg/dL), and history of supraventricular arrhythmia with or without treatment by anti-arrhythmic drugs. RESULTS: Postoperative AF occurred in 2 patients in the cibenzoline group (2/35, 5.7%) and 20 patients in the control group (20/59, 33.9%). There were significant differences in the incidence of postoperative AF (p = 0.002). Multivariate analysis revealed that the administration of cibenzoline reduced the incidence of AF significantly, and that a large number of bypass grafts significantly contributed to postoperative AF in CABG. The number of bypass grafts was significantly larger in the cibenzoline group, indicating that cibenzoline administration significantly suppresses the incidence of AF after CABG in high-risk patients. CONCLUSIONS: Postoperative administration of oral cibenzoline for 10 days is one effective method for the prevention of AF after CABG.

Sex steroid hormone receptors in human thymoma.

In this study we examined the immunohistochemical localization of sex steroid receptors for estrogen alpha (ER alpha) and ER beta, progesterone-A (PR-A) and PR-B, and androgen (AR) in human thymoma (n = 132) and correlated these findings with various clinicopathological parameters. We used RT-PCR and real-time PCR to further study the expression of these receptors in 20 thymoma cases. Immunoreactivity for all sex steroid receptors was detected in the nuclei of thymoma epithelial cells. The percentage of immunopositive cases and the H-score values for each receptor (mean +/- SD) were: ER alpha, 66% and 85.8 +/- 80.2; ER beta, 7% and 7.2 +/- 8.7; PR-A, 4% and 2.7 +/- 4.9; PR-B, 49% and 55.8 +/- 68.3; and AR, 15% and 14.1 +/- 11.7, respectively. The results of real-time PCR were consistent with those of immunohistochemistry, especially results for ER alpha, PR-B, and AR. A significant positive correlation was detected between immunoreactivity for ER alpha and PR-B. ER alpha immunoreactivity was inversely correlated with tumor size, clinical stage, WHO classification, and Ki-67 labeling index. In addition, the status of ER alpha immunoreactivity was significantly associated with a better clinical outcome in thymoma patients. Results from our study suggest that estrogens may inhibit thymoma growth via ER alpha, and that ER alpha immunoreactivity may act as a prognostic factor in human thymoma.

Formation of tissue factor-bearing leukocytes during and after cardiopulmonary bypass.

During cardiopulmonary bypass (CPB), the extrinsic coagulation system initiated by tissue factor (TF) is a major procoagulant stimulus. TF is present in surgical wounds and could be expressed on activated monocytes. However, recent studies have suggested that collagen stimulation rapidly induces TF by leukocyte-platelet complex formation. Therefore, the appearance of TF-bearing leukocytes and their effect on promoting coagulation were investigated in 5 patients undergoing coronary bypass surgery. Neutrophils and monocytes positive for CD41a and TF increased abruptly in circulating blood during CPB. Their increase was most prominent in blood pooled in the pericardial cavity. Monocytes, but not neutrophils positive for TF showed a second peak one day after operation, which accords with the increase in TF mRNA levels in leukocytes. Similarly, an increase in leukocytes positive for TF accords with the activated factor X generation assay using isolated leukocytes, and with an increase in thrombin-antithrombin complex in circulating blood. The second increase in TF-positive monocytes seems to be responsible for these coagulation parameters that remained high one day after operation. After 10 min of blood incubation stimulated by collagen in vitro, simulating activation in the pericardial cavity, significant increases in neutrophils and monocytes positive for TF and platelet were observed. Our present study suggested the involvement of two distinct mechanisms for the appearance of TF-bearing leukocytes responsible for promoting coagulation: the quick appearance being partly explained by the formation of leukocyte-platelet complex that occurs mainly in the pericardial cavity, and the slow appearance via transcriptional activation in monocytes.

Lipopolysaccharide pretreatment attenuates myocardial infarct size: A possible mechanism involving heat shock protein 70-inhibitory kappaBalpha complex and attenuation of nuclear factor kappaB.

OBJECTIVE: Lipopolysaccharide pretreatment is known to reduce myocardial infarct size, but the mechanism has not been elucidated. We hypothesized that heat shock protein 70, induced by lipopolysaccharide pretreatment, formed complexes with inhibitory kappaBalpha, thereby inhibiting degradation and attenuating activation of nuclear factor kappaB and cellular injury in rat myocardium. METHODS: Fifteen Sprague-Dawley rats were given saline solution (control group) or lipopolysaccharide. After 48 hours, 5 hearts in each group were excised without ischemia for examination of heat shock protein 70 and inhibitory kappaBalpha levels and detection of heat shock protein 70-inhibitory kappaBalpha complexes. Myocardium from the remaining 10 rats in each group was exposed to 30 minutes of ischemia and 30 minutes of reperfusion (n = 5) to evaluate nuclear factor kappaB activity or to 24 hours of reperfusion (n = 5) to evaluate infarct size. RESULTS: Infarct size was reduced in the lipopolysaccharide group (P <.05). Nuclear factor kappaB was activated in the control ischemia group and attenuated in the lipopolysaccharide group (P <.05). Heat shock protein 70 levels were increased in the lipopolysaccharide group (P <.05), but inhibitory kappaBalpha levels were similar in both groups. Heat shock protein 70-inhibitory kappaBalpha complexes were detected only in the lipopolysaccharide group. Colocalization of the 2 proteins was observed in the lipopolysaccharide group. CONCLUSIONS: Heat shock protein 70, induced by lipopolysaccharide pretreatment, forms complexes with inhibitory kappaBalpha and attenuates activation of nuclear factor kappaB and myocardial infarct size. Our results suggest that attenuation of nuclear factor kappaB through a mechanism forming heat shock protein 70-inhibitory kappaBalpha complexes might protect the myocardium from ischemia-reperfusion injury.

An increase in urinary nitrite/nitrate excretion is associated with the hyperdynamic state after cardiovascular surgery.

OBJECTIVES: To test the hypotheses (1) that nitric oxide (NO) production is stimulated after cardiovascular surgery and is related to the hyperdynamic state and (2) that NO production is more prominent in patients with cardiopulmonary bypass. DESIGN: Prospective, clinical study. SETTING: Intensive care unit in a university hospital. PATIENTS: One hundred patients after cardiovascular surgery: coronary artery bypass graft with (n=53) and without (n=17) cardiopulmonary bypass, valve surgery with cardiopulmonary bypass (n=23) and thoracic aortic replacement with cardiopulmonary bypass (n=7). INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Urinary nitrite/nitrate (NOx) excretion was measured by the high-performance liquid chromatography-Griess system as an index of endogenous NO production during the first 2 postoperative days. Hemodynamic variables, hematologic variables and serum C-reactive protein concentrations were measured after the operation. Urinary NOx concentrations were 146+/-70 and 190+/-93 micro mol/l, and the amounts of NOx excreted in the urine were 23+/-10 and 18+/-8 micro mol/h on the 1st and 2nd days, respectively. Urinary NOx excretions were positively correlated with the cardiac index (P<0.01), but inversely correlated with the systemic vascular resistance index (P<0.01). Urinary NOx concentrations were positively correlated with serum C-reactive protein concentrations (P<0.01), but inversely correlated with the cardiopulmonary bypass time (P<0.01). The urinary NOx concentration was highest in patients undergoing coronary artery bypass graft without cardiopulmonary bypass. CONCLUSION: These findings suggest, firstly, that NO production is stimulated by a surgical inflammatory response and, secondly, that the endogenous NO contributes to the increase in cardiac output that accompanies the reduced systemic vascular resistance after cardiovascular surgery.

Resection of endobronchial hamartoma by bronchoplasty and transbronchial endoscopic surgery.

Endobronchial hamartoma is a rare, benign tumor usually associated with pneumonitis and atelectasis caused by obstruction. Lobectomy is sometimes performed even if the tumor is benign. Transbronchial endoscopic surgery is usually performed for patients with a small endobronchial hamartoma. We report our treatment of a large hamartoma completely obstructing the patient's left main bronchus. The tumor was partially resected, and that remaining was resected by transbronchial endoscopic surgery. No finding of recurrence of the endobronchial hamartoma was detected by endoscopy or biopsy for 3 years. A combination of bronchoplasty and transbronchial endoscopic surgery benefits patients with large endobronchial hamartoma by preserving the lung parenchyma.

Double-patch technique for postinfarction ventricular septal perforation.

A modified infarct-exclusion technique for postinfarction ventricular septal perforation is presented. The perforation is closed directly by a small patch next to the conventional patch, and biological glue is applied between the patches to induce stable polymerization. The patch stuck to the infarcted septum, and no residual shunt was observed in any patient because the wide adhesion prevents excessive pressure on the suture line. Seven of 9 patients in whom this method was used had good results. This technique appears suited for repair of ventricular septal perforations, especially those with extensive fresh infarction.

Biventricular pacing with coronary bypass and Dor's ventriculoplasty.

We applied biventricular pacing to a patient with severe ischemic dilated cardiomyopathy (left ventricular [LV] ejection fraction 19%, LV end-diastolic volume 360 mL, and complete left bundle branch block). An epicardial LV lead was surgically implanted concomitant with on-pump beating coronary artery bypass grafting and Dor's endoventricular circular patch plasty. Biventricular pacing immediately achieved the resynchronization of the LV contraction, and improved cardiac function as well as reducing mitral regurgitation. Biventricular pacing combined with cardiac surgery for patients with cardiomyopathy and complete left bundle branch block may produce beneficial effects on LV function.