Usefulness of electromagnetic flowmetry in intraoperative evaluation of aortic regurgitation associated with ventricular septal defect.

In 38 patients with aortic regurgitation (AR) associated with ventricular septal defect (VSD), indications for aortic valvuloplasty (AVP) or aortic valve replacement (AVR) were investigated by assessing AR ratio, which was measured by electromagnetic flowmetry of the ascending aorta during the operation. Residual AR was evaluated by auscultation postoperatively. Patients were assigned to group A if they underwent VSD closure alone and to group B if they underwent AVP in addition to VSD closure; patients who had no postoperative AR were assigned to group I and those with persistence of AR to group II. Thus, the patients were separated into 4 subgroups; A-I (9 patients), A-II (5 patients), B-I (20 patients) and B-II (4 patients). In subgroup A-I, mean AR ratio decreased from 9% to 7% postoperatively, in A-II from 19% to 16% (p less than 0.1), in B-I from 36% to 9% (p less than 0.01) and in B-II from 44% to 20% (p less than 0.05). An AR ratio of more than 25% should be regarded as an absolute indication for AVP or AVR. If the AR ratio is between 20 and 25%, the indication of AVP is determined by inspection of the aortic valve. A good correlation was found between AR ratio and the AR rate determined by the aortic angiographic findings (Sellers classification): grade I AR corresponded to an AR ratio of 5 to 15%, grade II to 20 to 35%, grade III to 25 to 50% and grade IV to 45% or higher (r = 0.87, p less than 0.01).

Needlescopic surgery for palmar hyperhidrosis.

OBJECTIVE: The aim of this study was to develop a less invasive technique for video-assisted thoracic sympathectomy. METHODS: A newly designed trocar was used. A skin incision of 2.0 to 2.5 mm in length was made in the third or fourth intercostal space at the midaxillary line. After insertion of the trocar, thoracic sympathectomy with electrocautery was carried out at the level of the second and third ribs. RESULTS: From October 1998 to March 1999, 180 patients with palmar hyperhidrosis underwent this technique. No complications related to the technique occurred, and within 1 week the operative wound had almost completely disappeared. There were recurrences necessitating reapplication of the technique. CONCLUSION: The technique allowed healing without a scar and improved the patient's cosmesis.

Reoperation after aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect.

Five patients underwent reoperations because residual or recurrent aortic regurgitation occurred after aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect. The mean age at reoperation was 22 years old, and the mean time interval between initial and second operation was 6 years, 10 months. The pathological findings of the aortic valves showed tears and perforation of repaired leaflets in four patients and a giant pseudoaneurysm of the Valsalva sinus in one. Aortic valvuloplasties were performed again in three patients, and aortic valves were replaced with prosthetic valves in two. Slight to moderate regurgitant murmurs are still audible in patients who underwent these valvuloplasties. Ventricular septal defects should be closed before aortic regurgitation develops. If it has developed, however, valvuloplasty should be considered as a first choice in young patients. For adult patients, aortic valve replacement is recommended.

Optimal flow of aorta-pulmonary artery shunt in patients with cyanotic heart disease.

An aorta-pulmonary artery shunt with an expanded polytetrafluoroethylene (Gore-Tex) tube graft (3 to 6 mm in diameter) was done in 33 cyanotic patients with complex congenital heart disease. The patients ranged from 14 days to 22 years old. In 28, the shunt flow (QB) was measured, and the optimal QB and graft size were determined. Nine patients had severe heart failure because of an excessively large shunt. Seven of these patients died, 5 early and 2 late after operation. The QBS in these 9 patients were extremely high; the QB index and the ratio of shunt flow to systemic flow (QB/QS) were 3.86 +/- 0.91 L/min/m2 (mean +/- standard deviation) and 52.4 +/- 9.7%, respectively. The QB index and the QB/QS of patients without severe cardiac failure were 1.49 +/- 0.92 L/min/m2 and 27.2 +/- 11.4%, respectively. In conclusion, the QB index, the QB/QS, or both should be maintained in the range of 1.6 to 2.4 L/min/m2 and 30 to 40%, respectively. In infants, however, it is advisable to control the flow at less than the range just given. Analysis of graft size in relation to body weight (BW, in kilograms) and body surface area (BSA, in square meters) showed that the optimal diameter (D, in millimeters) could be calculated by the following formulas: D = 1.88 In(BW) + 1.8 (r = .86) D = 0.87 In(BSA) + 5.3 (r = .73).

Mitral valve replacement with preservation of chordae tendineae and papillary muscles.

An operative technique for mitral valve replacement (MVR) with preservation of the chordae tendineae to the anterior leaflet as well as the posterior leaflet is reported. This technique consists of the division of the anterior leaflet into anterior and posterior segments, the shifting and reattachment of the divided segments to the mitral ring of the respective commissural areas, and the use of a low-profile bileaflet prosthetic valve. A comparison of left ventricular function data between patients having operation with this technique and those having operation with the conventional method of MVR revealed significantly better improvement in cardiac index (p less than 0.06), left ventricular end-systolic volume index (p less than 0.05), and left ventricular ejection fraction (p less than 0.10) in the former group. Left ventricular wall motion improved in the anterolateral (p less than 0.01) and apical areas (p less than 0.02) in patients operated on with our technique. Maintenance of continuity between the mitral annulus and papillary muscles is expected to have a beneficial effect on postoperative left ventricular performance in spite of increased afterload.

Changes in structure of the chromophore in the photochemical process of bovine rhodopsin as revealed by FTIR spectroscopy for hydrogen out-of-plane vibrations.

The hydrogen out-of-plane bending (HOOP) vibrations were studied in the difference Fourier transform infrared spectra of lumirhodopsin and metarhodopsin I by use of a series of specifically deuterated retinal derivatives of bovine rod outer segments. The 947 cm-1 band of lumirhodopsin and the 950 cm-1 band of metarhodopsin I were assigned to the mode composed of both 11-HOOP and 12-HOOP vibrations. This result suggests that the perturbation near C12-H of the retinal in the earlier intermediate, bathorhodopsin (Palings, van den Berg, Lugtenburg and Mathies, Biochemistry, 28 (1989) 1498-1507), is extinguished in lumirhodopsin and metarhodopsin I. Unphotolyzed rhodopsin and metarhodopsin I exhibited the 14-HOOP bands in the 12-D derivatives at 901 and 886 cm-1, respectively. Lumirhodopsin, however, did not show the 14-HOOP in the 12-D derivatives. The result suggests a change in geometrical alignment of the C14-H bond in lumirhodopsin with respect to the N-H bond of the Schiff base.

Evaluation of corrective surgery for tetralogy of Fallot from late results by multivariate statistical analysis.

From 1966 to 1985, 469 pediatric patients with the tetralogy of Fallot (mean age, 4.9 years) were corrected (hospital mortality 11.9%). There were 9 late deaths (1.9%). In 186 patients, hemodynamic studies were performed 2-14 years postoperatively (mean age, 10.4 years). An increased cardiothoracic ratio (CTR) of 60% or more was found in 42 patients with impaired postoperative physical activity. The factors affecting the late results were investigated in relation to CTR by the quantification method of multivariate analysis. As for the enlarged CTR, pulmonary regurgitation was more of a contributing factor than pulmonary stenosis. In pulmonary regurgitation, the pulmonary artery area index (PAAI) and reconstruction of the right ventricular outflow tract (RVOT) were highly significant factors. For pressure gradient, the VSD site was the most significant factor. These analyses suggest that preservation and/or reconstruction of the pulmonary valve, or trans-annular patching with the necessary minimal area for the RVOT (PAAI) not to exceed 4 cm2/m2 at the time of operation is important for satisfactory late results.

Estimation of an unexpected-overlooking error by means of the single eye fixation related potential analysis with wavelet transform filter.

An unexpected-overlooking error that caused failure to notice near the peripheral vision is one of the accident factors in driving behavior. We estimated how the unexpected-overlooking error affected the amplitude of the lambda wave in the eye fixation related potential (EFRP). Four subjects participated in the experiment. Each subject was required press the right or left switch according to the given task, which was that he/she pressed the right switch when the blue dot appeared in the right detected area or he/she pressed the left switch when the red dot appeared in the right. The single trial data from Pz, which referred to both earlobes, were analyzed by means of a wavelet transform (WT) filter. The difference of the lambda amplitude between the corrected data was applied for analysis of variance. Three subjects showed a significant effect (P<0.01 or P<0.05), and the remaining one subject did not show a significant consequence of only two errors. The unexpected-overlooking errors had a low amplitude compared to the mean of amplitude throughout the task. It was concluded that the amplitude of the lambda wave might reflect the attention level of a subject.

Noninvasive assessment of the autonomic nervous tone in angina pectoris: an application of digital plethysmography with auditory stimuli.

To assess the relationship between autonomic nerve activity and the anginal attack, we examined the daily variation of the autonomic tones employing digital plethysmography with auditory stimuli, and also tested the daily variation of exercise capacity. Thirteen of 45 cases (28.9%) of spontaneous angina, excluding Prinzmetal's angina, complained of typical chest discomfort or pain especially in the morning. They manifested an augmented level of the autonomic nerve activity and positive stress testing. The remainder did not demonstrate these abnormal findings in the morning. For the 13 cases, calcium antagonists were given orally immediately after awakening. This resulted in the complete relief from chest discomfort or pain. These findings suggest that an autonomic imbalance plays an important role in the pathogenesis of this type of anginal attack. Thus, the estimation of the daily variation of autonomic nervous tone would be valuable for the diagnosis and treatment of angina pectoris.

A 90-year old patient with atrial septal defect and sinus rhythm.

A 90-year old patient with an atrial septal defect (ASD) and sinus rhythm, but no history of atrial fibrillation of heart failure is presented. Literature searches revealed no similar report of such a case. In addition, this patient represents the oldest documented patients with ASD associated and sinus rhythm.

[Subsegmental transcatheter hepatic arterial embolization under balloon occlusion of the corresponding hepatic vein with SMANCS].

Recently, subsegmental transcatheter hepatic arterial embolization under balloon occlusion of the corresponding hepatic vein has been performed to treat hepatic infarction in subregion hepatocellular carcinoma (HCC). Here, we report subsegmental transcatheter hepatic arterial embolization under balloon occlusion of the corresponding hepatic vein with styrene maleic acid neocarzinostatin lipiodol (SMANCS) (SMANCS-TAE under balloon occlusion of the corresponding hepatic vein). This study included 9 patients with HCC who underwent SMANCS-TAE under balloon occlusion of the corresponding hepatic vein. In all patients, the therapeutic effects (TE) were evaluated according to the criteria of direct response to liver cancer treatment on abdominal computed tomography (CT) 3 weeks after surgery. In 7 patients who could be followed for more than one year, there was no postoperative relapse at the site of treatment. Furthermore, this procedure facilitated the detection of accumulation of SMANCS not only in the tumor but also in the subregion of the tumor in patients with HCC involving immature arterial tumor neoplastic vessels. In patients with large HCC complicated by severe heart failure showing a poor general condition, this procedure allowed treatment to be completed without complication. SMANCS-TAE under balloon occlusion of the corresponding hepatic vein, which can also embolize the portal vein by applying targeting chemotherapy with SMANCS, may cause necrosis not only in the tumor but also in noncancerous liver tissues. This procedure may be an indication for a larger number of cases than standard TAE, facilitating more complete local treatment.

[Mitral valve replacement with preservation of whole papillary muscles and chordae tendineae].

A total of 20 patients underwent mitral valve replacement (MVR) with preservation of the papillary muscles (PM) and chordae tendineae (CT) with the object of maintaining left ventricular contractility and decreasing the risk of left ventricular rupture after surgery. The patients comprised of 8 males and 12 females whose ages ranged from 33 to 67 years. In 8 patients, the posterior leaflet was left in place and in 12, the CT to the anterior leaflet were also preserved by excision of the central portion and reattachment of the rest of the leaflet to the appropriate commissural regions. St. Jude Medical valves were exclusively employed as a substitute. Reasons for MVR were isolated MR in 12 cases, MRs in 5 and MSr in 3. There were one operative, one hospital and one late death respectively. Postoperative C.I. increased from 2.65 +/- 0.48 to 3.8 +/- 0.75 ml/min./M2 and LVEF increased from 55.1 +/- 11.4 to 63.4 +/- 13.4%. The area method showed marked improvement of segmental wall motion in anterolateral regions. Chordal shortening also disclosed improvement in long axis. Preservation of papillary muscles and chordae tendineae during MVR has been found to have a beneficial effect on postoperative left ventricular contractility.