Revisiting DARPP-32 in postmortem human brain: changes in schizophrenia and bipolar disorder and genetic associations with t-DARPP-32 expression.

Dopamine- and cAMP-regulated phosphoprotein of molecular weight 32 kDa (DARPP-32 or PPP1R1B) has been of interest in schizophrenia owing to its critical function in integrating dopaminergic and glutaminergic signaling. In a previous study, we identified single-nucleotide polymorphisms (SNPs) and a frequent haplotype associated with cognitive and imaging phenotypes that have been linked with schizophrenia, as well as with expression of prefrontal cortical DARPP-32 messenger RNA (mRNA) in a relatively small sample of postmortem brains. In this study, we examined the association of expression of two major DARPP-32 transcripts, full-length (FL-DARPP-32) and truncated (t-DARPP-32), with genetic variants of DARPP-32 in three brain regions receiving dopaminergic input and implicated in schizophrenia (the dorsolateral prefrontal cortex (DLPFC), hippocampus and caudate) in a much larger set of postmortem samples from patients with schizophrenia, bipolar disorder, major depression and normal controls (>700 subjects). We found that the expression of t-DARPP-32 was increased in the DLPFC of patients with schizophrenia and bipolar disorder, and was strongly associated with genotypes at SNPs (rs879606, rs90974 and rs3764352), as well as the previously identified 7-SNP haplotype related to cognitive functioning. The genetic variants that predicted worse cognitive performance were associated with higher t-DARPP-32 expression. Our results suggest that variation in PPP1R1B affects the abundance of the splice variant t-DARPP-32 mRNA and may reflect potential molecular mechanisms implicated in schizophrenia and affective disorders.

[Volume reduction surgery for giant coronary sinus with valvular heart disease; report of a case].

A 64-year-old male with giant left atrium and giant coronary sinus, who had aortic valve regurgitation, prosthesis valve paravalvular leakage in mitral position and prosthesis valve malfunction in tricuspid valve position, was successfully treated with double valve replacement, paravalvular leakage repair and volume reduction of left atrium and coronary sinus. Giant coronary sinus was about 70 mm in diameter and was thought to be induced by persistent left superior vena cava, high right atrium pressure and prosthesis valve malfunction in tricuspid valve position. Lung volume was so much increased by volume reduction of left atrium and coronary sinus and patient's symptoms were much improved.

[Full-thickness resection of the focus site for adolescent idiopathic ventricular tachycardia].

We present a case of a 14-year-old male with incessant idiopathic ventricular tachycardia for which both pharmacological and catheter ablation treatments failed. Curative surgery was performed on this patient. By intraoperative epicardial isochronous mapping, arrhythmogenic focus was identified in the right ventricular infundibulum between the large conus branch and the proximal right ventricular coronary branch. After cryoablation both from the epi- and endo-cardial sides failed to terminate the arrhythmia, subsequent full-thickness resection of the identified focus was performed. There was no postoperative recurrence of tachyarrhythmia In idiopathic ventricular tachycardia, arrhythmogenic focus is not always situated on the endo- or epicardial side. Full-thickness resection of the focus site might be necessary in such patients as we experienced this time.

[Reoperation for postoperative pseudoaneurysm after repair for acute aortic dissection associated with disseminated intravascular coagulation and chronic renal failure].

We report a very high risk case of reoperation for pseudoaneurysm after ascending aortic replacement for acute aortic dissection in a 78-year-old man with chronic renal failure and disseminated intravascular coagulation (DIC). Computed tomography 5 years after the 1st operation showed huge pseudoaneurysm originated from the distal anastomosis and the angiogram showed moderate aortic regurgitation. Hemodialysis and congestive heart failure associated with DIC complicated his general condition. Preoperative DIC score was 7 with D-dimer of 39.8 microg/ml. The patient underwent reoperation through night anterior thoracotomy. At 20 degrees C of urinary bladder temperature, we started re-median sternotomy and ablated the adhesion. When the pseudoaneurysm ruptured, we started hypothermic circulatory arrest with selective cerebral perfusion immediately. And Bentall operation and hemi-arch replacement were performed. Postoperative recovery required long period and he was transferred to another hospital at 3 months after the surgery. Postoperative data showed reduction of DIC score to 3.

[Valve-in-valve replacement of primary tissue valve failure of bovine pericardial valve minor].

A 73-year-old woman who underwent mitral valve replacement with a 31 mm Carpentier Edwards Pericardial Xenograft 19 years ago. She revealed sudden onset of a grade IV/VI a seagull like diastolic murmur at the apex, and severe hematuria. Echocardiography demonstrated severe mitral regurgitation. These findings were consistent with acute primary tissue valve failure. Therefore we performed emergency reoperation. At operation, valve leaflet was torn at the commissural stitch, and bioprosthesis strut was buried in the left posterior ventricular wall. The mitral prosthetic valve replaced with a 25 mm CarboMedics OptiForm using a technique of valve-in-valve replacement. This procedure would be one option for replacement of bioprosthetic mitral valve.

Postoperative chemotherapy including intraperitoneal and intradermal administration of the streptococcal preparation OK-432 for patients with gastric cancer and peritoneal dissemination: a prospective randomized study.

We studied the effects on survival time of postoperative immuno-chemotherapy, including the streptococcal preparation OK-432, in patients with gastric cancer and synchronous peritoneal dissemination. The patients were prospectively randomized and a valid statistical assessment could be made for 109. Patients randomized to group B received therapy that is widely used in Japan to treat patients with gastric cancer: mitomycin C (MMC) and UFT, a combination of tegafur and uracil in a molar ratio of 1:4, for 1 year. Patients randomized to group A received the same drugs as were given to group B patients plus OK-432 i.p. for 7 days, beginning on postoperative day 0, and OK-432 by intradermal injection for 1 year, at 2-week intervals. There were no differences between the two groups in any known prognostic factor or in the dose of any drug administered except for OK-432. There was no difference in the toxicity rate between the groups. In this negative trial, there was no improvement in survival time with the addition of OK-432 to MMC and UFT for patients with gastric cancer and peritoneal dissemination.

Chemosensitivity of gastric-cancer using adhesive tumor-cell culture system.

A total of 91 specimens of surgically resected tumors from 80 patients with gastric cancer were assayed for chemosensitivity using an adhesive tumor cell culture system (Life Trac ATCCS assay). Seventy-eight specimens of 91 had sufficient number of cells to grow in culture and 64 (82%) were evaluable excluding 8 low growth and 6 fungus contaminations. Cells (3x10(3)/ml/well) were cultured for 14 days and exposed to drugs on days 3-8. The growing cells were confirmed as cancer cells by immunohistochemical staining using monoclonal antibody to cytokeratin, epithelial membrane antigen and vimentin. IC90 value against (ADM, CDDP, CPM, 5-FU, MMC, MTX, VP-16, CBDCA and MMC+5-FU+MTX) was determined and population distribution of IC90 for each drug was obtained to serve as basic data for judging sensitivity. The 10th percentile of IC90 (mug/ml) was 0.01, 0.43, 1.23, 0.23, 0.01, 0.005, 0.14, 1.56 and 0.009+0.05+0.003 and median of IC90 was 0.02, 0.99, 2.31, 0.30, 0.06, 0.01, 0.39, 3.19 and 0.02+0.10+0.005, respectively. Population distribution of IC90 against each drug showed a specific pattern. Profiles of IC90 against various anticancer drugs differed in individual patients. Chemosensitivity of lymph node metatases seemed to be more resistant than that of their primary tumors. The ATTCS test was found to be useful as a sensitivity test for anti-cancer agents because of its reliability and excellent quantification.

Prognostic factors of gastric cancer tumours of less than 2 cm in diameter: rationale for limited surgery.

BACKGROUND: A recent trend in the surgical treatment of patients with early gastric cancer in Japan has been to limit surgery to an extent that ensures complete cure and improvement in the patient's quality of life. If a gastric cancer tumour can be completely eradicated by laparoscopic surgery, the patient can be cured of cancer without major operative stress. A small gastric cancer tumour of less than 2 cm in diameter is an indication for laparoscopic surgery, but little is known about what protocol of surgical treatment is appropriate for this type of tumour. PATIENTS AND METHODS: The clinicopathological features of 150 patients with gastric cancer tumour of less than 2 cm in diameter were reviewed retrospectively from hospital records between 1985 and 1995. The results of retrospective analysis of clinicopathological data of 24 patients with advanced cancer were compared with those of 126 patients with early cancer. Univariate and multivariate analyses of patients with small gastric cancer tumours were performed to evaluate the prognostic significance of clinicopathological features. RESULTS: A significant difference was seen between the gross tumour appearances in the two groups; Borrmann type-4 tumours were more common in the advanced group. Lymph-node metastasis, lymphatic vessel invasion and vascular invasion were found more frequently in the advanced cancer group than in the early cancer group. Scirrhous type was more common in the advanced cancer group. In univariate analysis, unfavourable prognostic factors included deep cancer invasion, presence of lymph-node metastasis, lymphatic invasion and vascular invasion. Using Cox's proportional hazard regression model, only nodal involvement emerged as an independent statistically significant prognostic parameter associated with long-term survival. CONCLUSION: Laparoscopic surgery should not be performed on tumours that are Borrmann type in macroscopic appearance and scirrhous-type histologically. Lymph-node metastasis is an independent prognostic factor. We recommend laparoscopic surgery involving local resection of the stomach without lymphadenectomy for small, early gastric cancer tumours that satisfy the criteria mentioned above. However, the validity of this recommendation should be tested by a prospective randomized control trial in the future.

c-erbB-2, p53 protein expression and steroid hormone receptors in breast carcinomas: an immunohistochemical study.

p53, c-erbB-2 protein, steroid hormone receptors, and their correlation with clinicopathologic features were investigated in 70 primary breast carcinomas. All markers were measured immunohistochemically on paraffin sections. Altered p53 expression was found in 27.1% of cases and was associated with negative estrogen receptor status. p53 immunostaining was correlated weakly with histologically lymphatic vessel invasion of carcinoma. c-erbB-2 protein overexpression was seen in 48.6% of cases. A trend was observed in the correlation between c-erbB-2 immunostaining and regional lymph node metastases. Estrogen receptor status was not associated with any histologic or clinical parameters, whereas progesterone receptor status was associated with lymph node metastasis and histologically lymphatic vessel invasion of cancer. PgR status, p53 and c-erbB-2 immunostaining may prove to be an additional criterion in histologic diagnosis of breast cancer.

Significant prognostic factors in patients with early gastric cancer.

BACKGROUND: Early gastric cancer is defined as a gastric carcinoma confined to the mucosa or submucosa regardless of lymph node status, and it has an excellent prognosis with a 5-year survival rate of more than 90%. From 1985 to 1995, we encountered 266 cases of early gastric cancer in our hospital. METHODS: A retrospective analysis of the 266 cases of early gastric cancer was performed to evaluate the prognostic significance of clinicopathological features (age, gender, tumor size, tumor location, depth of invasion, lymph node metastasis, histological type, lymphatic invasion, vascular invasion, histological growth pattern, cancer-stromal relationship and type of operation). RESULTS: The overall survival rate of all the patients with early gastric cancer was 95.7%. In univariate analysis, the statistical significant prognostic factors were regional lymph node metastasis (P = 0.0004), lymphatic invasion (P = 0.0053) and cancer-stromal relationship (P = 0.0016). Absence of lymph node metastasis and lymphatic invasion, and a medullary-type histopathology were associated with improved survival. In multivariate analysis, the statistically significant prognostic factors were lymph node metastasis and cancer-stromal relationship. CONCLUSIONS: Presence of lymph node involvement and a scirrhous type of gastric cancer are associated with poor prognosis. Lymph node dissection with gastric resection is necessary for patients with early gastric cancer who have a high risk of lymph node metastasis. Postoperative chemotherapy is recommended for a scirrhous type of early gastric cancer.

Lymph node metastasis in early gastric cancer: how can surgeons perform limited surgery?

BACKGROUND: In Japan, the standard treatment policy for all potentially curable patients with gastric cancer is radical resection, including extensive lymph node dissection. The extent of lymph node dissection remains a controversial issue in the management of early gastric cancer. A recent trend in the surgical treatment of early gastric carcinoma has been to limit surgery such that a complete cure is achieved and the patient's quality of life is improved. However, approximately 10% of early gastric cancers are reported to be node positive and little is known about the protocol of surgical treatment most appropriate for the treatment of early gastric cancer. In this study, we examined the clinicopathological features that could distinguish node-positive cancer from node-negative cancer. PATIENTS AND METHODS: The clinicopathological features of 26 patients with node-positive early gastric cancer were reviewed from the database of gastric cancer at the Department of Surgery, Sendai National Hospital. They were compared with those of 239 patients with node-negative cancer. RESULTS: Tumor size, macroscopic appearance, depth of cancer invasion, histological growth pattern and lymphatic invasion were associated with lymph node metastasis. Node-positive patients with early gastric cancer had a poorer survival rate than node-negative patients (P<0.05). CONCLUSION: Limited surgery, such as local resection without lymphadenectomy, can be performed for elevated or flat type cancer, or tumor <2 cm in diameter. Lymphadenectomy is recommended to achieve higher possible cure rates for other early gastric cancers.

Gastric cancer with invasion limited to the muscularis propria.

The clinicopathological features of 84 muscularis propria (mp) gastric cancers, defined as gastric cancer invading the muscularis propria of the stomach, were reviewed retrospectively, and compared with 267 early gastric cancers (m/sm cancer) and 333 gastric cancers invading beyond the subserosal layer (ss-si cancer). There were statistical differences in tumor size, histological growth pattern, cancer-stromal relationship, lymph node metastasis, lymphatic invasion, vascular permeation and operative procedure between mp gastric cancer and early gastric cancer or ss-si gastric cancer. The mp tumors were significantly larger than the early cancer tumors but significantly smaller than the ss-si tumors (P < 0.0001), and mp cancer had more frequent lymph node metastasis (50%) than did early gastric cancer (10%) but less frequent lymph node metastasis than did ss-si cancer (84%; P < 0.0001). Histologically, infiltrative and scirrhous types were more common in the mp cancer group than in the early cancer group. The frequency of vascular permeation in the mp cancer group was almost the same as that in the early cancer group. Univariate analysis revealed that the significant prognostic factors were nodal involvement (P = 0.0213) and lymphatic invasion (P = 0.0364). Multivariate analysis of the mp-invaded cancer cases, however, revealed that lymph node metastasis was not a significant prognostic factor, although it was more important than was lymphatic invasion. Multivariate analysis also revealed that the prognosis of our mp gastric cancer patients was affected most by vascular permeation, followed by tumor size.

Significant prognostic factors in patients with node-negative gastric cancer.

BACKGROUND: We evaluated the influence of several clinicopathological variables on 5 year survival of patients with node-negative gastric cancer. PATIENTS AND METHODS: Clinical characteristics were retrieved from the records of all patients who underwent gastric resection between 1985 and 1995 at the Department of General Surgery, Sendai National Hospital, and follow-up data were obtained from our tumor registry. Pathological characteristics were determined from a detailed review of all available histopathological slides. The results of a retrospective analysis of clinicopathological data of 339 patients having no lymph node metastasis were compared with those of 358 patients with lymph node metastasis. Univariate and multivariate analyses of patients with node-negative gastric cancer were performed to evaluate the prognostic significance of clinicopathological features (age, gender, gross type, histological type, depth of invasion and location). RESULTS: The 5 year survival rate for patients with node-negative gastric cancer was 92.5%. Node-negative gastric cancers were characterized by a smaller tumor, expansive and medullary histological type, and less frequency of lymphatic invasion and vascular permeation. In multivariate analysis, the statistical significant prognostic factors were tumor size (P = 0.0185), vascular permeation (P = 0.0011) and cancer-stromal relationship (P = 0.0291). CONCLUSION: Tumor size, vascular microinvasion and cancer-stromal relationship are the most reliable predictors of 5 year survival for patients with node-negative gastric cancer.

Probability of lymph node metastasis in small gastric cancer tumor: is it an indication for limited surgery?

The purpose of this study was to determine the factors that are predictive of lymph node metastasis in a small gastric cancer tumor <2 cm in diameter. The clinicopathological features of 17 patients with node-positive small gastric cancer were reviewed from the database of gastric cancer at the Department of Surgery, Sendai National Hospital, Sendai, Japan, and they were compared with those of 131 patients with node-negative cancer. The independent risk factors influencing the lymph node metastasis were determined by multiple logistic regression analysis. Depth of invasion, macroscopic appearance, cancer-stromal relationship, and lymphatic microinvasion were found to be associated with lymph node metastasis. The variables found to be significant risk factors for lymph node metastasis were depth of invasion (P = 0.0250) and lymphatic microinvasion (P = 0.0028). It is possible for even a small gastric cancer tumor to have lymph node metastasis. A surgeon treating a small gastric cancer tumor must consider that although the cure rate is high, >10% of these tumors have lymph node metastases. Because of the possibility of lymph node metastasis, even with accurate knowledge of the depth of cancer invasion, selective performance of local resection or limited surgery with incomplete lymph node dissection is not justified. Accurate preoperative diagnosis and the appropriate decision for surgical indication are important. Large-scale randomized, controlled trials should be performed to show the advantage of limited surgery for gastric cancer.

Malignant fibrous histiocytoma: a method to control intraoperative hemorrhage by clamping the feeding arteries.

Malignant fibrous histiocytoma (MFH), also referred to in the past as malignant fibrous xanthoma and fibroxanthosarcoma, is a tumor of mesenchymal tissue origin. A case of retroperitoneal MFH was reported. In this paper, we describe a method of hemostasis and intraoperative control of hemorrhage during resection of retroperitoneal MFH by snaring the feeding arteries. The patient was successfully operated on using this technique.

Poorly differentiated, solid-type adenocarcinoma of the stomach.

Data of 58 cases of poorly differentiated, solid-type adenocarcinoma of the stomach treated at our hospital between 1985 and 1995 were reviewed and compared to data of 146 cases of non-solid-type carcinoma in order to determine whether there are distinguishable clinicopathological features between these two types of carcinoma. Significant differences were observed with respect to tumor size, stage, macroscopic appearance, depth of invasion, histologic growth pattern, lymph node metastasis, microscopical lymphatic invasion and vascular permeation. Patients in the solid-type cancer group tended to have smaller tumors; the disease was in the early stage in 48% of the patients, and total gastrectomy was performed in only 20 of the 58 patients. Nodal involvement, lymphatic invasion and vascular permeation were also less common in patients with solid-type cancer. The overall survival rate of patients with solid-type carcinoma was higher than that of patients with non-solid-type carcinoma, though no significant differences were observed when corrected for stage. Our results suggest that poorly differentiated solid-type carcinoma of the stomach should be regarded as a distinct type of adenocarcinoma that has a good prognosis. The significant prognostic factors for this type of gastric cancer are lymphatic invasion and tumor location.

Clinicopathologic prognostic features in patients with gastric cancer associated with esophageal or duodenal invasion.

BACKGROUND: We evaluated the influence of several clinicopathologic variables on 5-year survival of patients with gastric cancer associated with esophageal or duodenal invasion, and determined the significance of resection line involvement. PATIENTS AND METHODS: A review of the database for gastric adenocarcinoma at Sendai National Hospital between January 1985 and December 1995 identified 923 patients who underwent gastric cancer resection. Of these patients, 37 were reported to have tumour infiltration of the esophagus or duodenum on histological examination of the resected specimens. Univariate and multivariate analyses of patients with esophageal or duodenal invasion were performed to evaluate the prognostic significance of clinicopathologic features. Then the patients were divided into two groups based on the results of microscopic examination: a tumour wedge-positive group for resection margins of less than 5 mm in width and a tumour wedge-negative group for resection margins of more than 5 mm in width. There were 8 patients in the narrow (margin-positive) group and 29 patients in the wide margin (margin-negative) group, respectively. RESULTS: Univariate analysis revealed that the significant prognostic factors were nodal involvement (p=0.0004) and gross type (p=0.0031). Multivariate analysis of the esophagus or duodenum-invaded cancer cases, however, revealed that only nodal involvement was a significant prognostic factor. There were statistical correlations between these groups (margin-positive and margin-negative groups) and the Borrmann type of tumour and tumour size. The survival rate was worse in patients with tumour line involvement. CONCLUSIONS: Multivariate analysis revealed that the prognosis of patients with esophageal or duodenal invasion was affected only by nodal involvement independently. The risk of surgical margin involvement was high in cases of a large Borrmann type-4 tumour and infiltrative carcinoma.

Clinicopathologic prognostic factors in patients with Borrmann type 4 gastric cancer: univariate and multivariate analyses.

BACKGROUND: Advanced gastric cancer is classified into four Borrmann types, types 1 to 4. Type 4 is a relatively undifferentiated carcinoma with little or no gland-forming capability. Despite recent advances in the diagnosis and surgical management of gastric cancer, most tumors of Borrmann type 4 are not detected at an early stage and the prognosis remains poor; the five-year survival rate after gastric resection ranges from 10 to 20 percent. We evaluated the affects of several clinicopathologic variables on the 5-year survival rate after resection of Borrmann type 4 gastric cancer. METHODS: Data on clinical characteristics were obtained from the records of patients who underwent gastric resection between 1985 and 1995 at the Department of Surgery, Sendai National Hospital, and follow-up data were obtained from our tumor registry. Pathologic characteristics were determined from a detailed review of all available histopathologic slides. The relationship between clinicopathologic variables and 5-year survival rate was estimated by the Kaplan-Meier survival curve and the logrank test. Multivariate Cox's proportional hazards regression analysis was then performed to determine which variables were independent prognostic factors. RESULTS: Eighty-seven patients with Borrmann type 4 gastric cancer underwent a resection during the study period at our hospital. The overall 5-year survival rate was 14.8%. The relationship between clinicopathologic variables and 5-year survival rate was determined by constructing a Kaplan-Meier survival curve. Tumor location (upper, middle and distal vs whole stomach, p=0.0214), lymph node metastasis, capillary microinvasion, and peritonitis carcinomatosa (absent vs present, p<0.05) significantly influenced survival. When multivariate analysis using Cox's proportional hazards regression of 5-year survival was performed, capillary microinvasion, peritonitis carcinomatosa (absent vs present) and tumor location (distal vs whole stomach) emerged as the statistically significant independent prognostic factors associated with long-term survival. CONCLUSION: Capillary microinvasion and the presence or absence of peritonitis carcinomatosa are more powerful predictors of 5-year survival than is lymph node metastasis. Patients with gastric cancer of the whole stomach have a poorer prognosis than do those with carcinoma in the antrum of the stomach.

[Combination use of second generation cephem and isepamicin for the treatment of post-surgical infection of the lower digestive tract].

Effects of combination use of a second generation cephem and an aminoglycoside antibiotic isepamicin (ISP), for the treatment of post-surgical infections of the lower digestive tract were examined from a laboratory and clinical perspective. Thirty-three out of total 35 cases were included in the analysis of the test, while the other 2 cases did not meet the criteria for analysis. ISP was administered in combination with one of the second generation cephems among cefotiam (CTM), cefmetazole (CMZ), or cefuroxime (CXM) for 26 cases of wound infection and 7 cases of peritonitis. The overall efficacy rate was 88%; 92% in wound infection and 71% in peritonitis individually. There was no significant difference in efficacy among different groups. Bacteriological study showed the combination use of any one of the second generation cephems and ISP was very effective in all 14 cases of infections with a single species of bacterium, the efficacy rate was 100%. It was also effective in 9 out of 10 cases with mixed infections of 2 species of bacteria (90%), but effectiveness was diminished in only 6 out of 9 cases with mixed infections of 3 species (67%). Sixty-nine strains were isolated from the 35 cases, more than half of which (44 strains) were Gram-negative; 14 strains of E. coli (20%), 13 strains of E. faecalis (13%) and 6 strains of P. aeruginosa (9%). The MIC50 and MIC90 were, respectively, 1.56 micrograms/ml and 100 micrograms/ml for ISP, 6.25 micrograms/ml and 100 micrograms/ml for CTM, 12.5 micrograms/ml and 100 micrograms/ml for CMZ, and 25 micrograms/ml and 100 micrograms/ml for CXM. The MICs in any combination uses decreased synergistically according to ISP concentration. Adverse events were observed in 3 out of 35 cases, but they were not severe. The results indicated that the combination use of a second generation cephem and ISP was useful and should be one of the choices for the treatment of post-operative infections of the lower digestive tract.

[A case of repeated surgical intervention for pulmonary venous obstruction after repair of total anomalous pulmonary venous connection].

A 3-month-old boy showed pulmonary venous obstruction after repair of total anomalous pulmonary venous connection. He was treated with a novel method of stureless in situ pericardium repair. Six weeks after this operation, he showed recurrence of venous obstruction and the same procedure was performed. Another six weeks after this operation, stenosis of the left pulmonary vein necessitated the same procedure again. Although he suffered from pneumonia and died of sepsis, this procedure revealed effectiveness for at least three months. This report showed clinical course after repeated stureless in situ pericardium repair. More experience will be necessary to evaluate the effectiveness of this procedure.