Pseudoaneurysm of the left ventricle following repair for ventricular septal perforation

The patient was a 64-year-old man who was treated surgically for an infarct-related ventricular septal perforation. Pseudoaneurysm of the left ventricle was recognized on the 38th postoperative day. Emergency surgery was performed. It seemed that insufficient resection of the infarcted myocardium was performed during the initial surgery to avoid narrowing the ventricular dimension by direct closure of the left ventricle, but this resulted in pseudoaneurysm of the left ventricle. Left ventricular free wall plasty with a patch should be performed during the initial surgery.     

Friedrich Daniel von Recklinghausen. Biography and significance of his osteopathologic work after more than 100 years

A new technique for post-infarction ventricular septal defect is accomplished by suturing a single patch to healthy endocardium excluding the infarcted area from the high left ventricular pressure. We have used this infarction exclusion technique for 3 cases since 1994. Three patients developed cardiogenic shock before operation and were managed initially with an intra-aortic balloon pump. All patients were urgently operated using this technique, at the same time, CABG operation was performed in 2 cases from the finding of preoperative coronary angiography. All of the patients survived. The first patient had a residual shunt (L-R; 30%), which spontaneously resolved in one month after the operation. In this method, a two-dimensional plane patch has to be sutured to healthy endocardium like a three-dimensional dome. Consequently the edge of the patch has wrinkles, which cause a residual shunt easily at the suture line. So from the second case, previously prepared circular conic patch, which had been made from a plane circular patch, was sutured to the left ventricular endocardium. At the suture line, this conic patch was well fitted to the endocardium, and the patients had no residual shunt. Though this method has the advantage to retain left ventricular function and volume, the technique must be improved to prevent residual shunt after operation.     

Heparin-binding EGF-like growth factor mRNA is upregulated in the peri-infarct region of the remnant kidney model: in vitro evidence suggests a regulatory role in myofibroblast transformation

Heparin-binding epidermal growth factor-like growth factor (HB-EGF) is a potent fibroblast and epithelial cell mitogen that may be important in wound healing. The aim of this study was to determine its distribution and possible function in segmental renal infarction. At day 1 postinfarction, in situ hybridization showed that HB-EGF mRNA was markedly increased by tubular epithelial cells bordering the infarcted zone. At day 3, typical myofibroblasts expressing alpha-smooth muscle actin (alpha-SMA) were present in large numbers at the peri-ischemic border and, over succeeding days, were also seen within the infarcted area. Some of these cells expressed HB-EGF mRNA by in situ hybridization suggesting possible autocrine stimulation. Endothelial cells appeared to be more resistant to ischemia than tubules because some capillaries at the periphery of the infarct, surrounded by infarcted tubules, also expressed HB-EGF mRNA. The staining intensity of HB-EGF mRNA in individual tubules and endothelial cells was maximal at day 5 after infarction, although Northern blots of tissue from the peri-infarct area only showed significantly increased expression of HB-EGF mRNA at days 1 and 3, perhaps reflecting a smaller area of greater intensity of expression at day 5. Because tubular cells expressing high levels of HB-EGF mRNA were directly apposed to myofibroblasts, an attempt was made to determine whether HB-EGF contributed to upregulation of alpha-SMA by human fibroblasts. Although stimulation of the fibroblast cell line MRC-5 with transforming growth factor-beta1 (TGF-beta1) increased alpha-SMA, HB-EGF reduced expression. HB-EGF also strongly inhibited the increased expression of alpha-SMA due to TGF-beta1. Because HB-EGF is a potent fibroblast mitogen and TGF-beta is usually antiproliferative, this study suggests that HB-EGF may contribute to a local balance between fibroblast proliferation and differentiation into myofibroblasts during scarring.     

Anatomic correction of transposition of the great vessels

We present a new approach for anatomic correction of transposition of the great arteries. The two coronary arteries, with a piece of the aortic wall attached, are transposed to the posterior artery. The two aortic openings are closed with a patch. The aorta and pulmonary artery are transected, contraposed, ant then anastomosed. The interventricular septal defect is closed with a patch, through a right ventriculotomy approach, because the right ventricle is no longer part of the systemic circulation. Two patients, aged 3 months and 40 days weighing 4,200 and 3,700 grams, respectively, were operated upon with deep hypothermia and total circulatory arrest. There was good recovery from the operation, with normal cardiocirculatory conditions. Renal failure developed in the first patient, and she died on the third postoperative day. During this time the cardiocirculatory conditions were good. The second patient made an uneventful recovery. Hemodynamic studies 20 days after the operation showed complete correction of the malformation. Five and one-half months after the operation, he weighs 7,500 grams, and his development is very good. We believe that this operation will be reproducible by most cardiovascular septal defect and pulmonary hypertension.     

Survey of hospital-based echocardiography services

A 73-year-old woman with acute myocardial infarction (Seg. 6: 100%) was admitted to our hospital. She underwent percutaneous transluminal angioplasty (PTCA) and stent insertion to Seg. 6 on that day and anticoagulant therapy with urokinase and heparin was started in CCU. On the 4th day, chest pain developed suddenly and echocardiography revealed cardiac tamponade, so we suspected left ventricular free wall rupture. When blood pressure increased to 100 mmHg in the operating room, the left ventricular free wall rupture became "blow out" type. After establishing extracorporeal circulation, we glued Xenomedica and autologous pericardium using gelatin-resorcin-formaldehyde glue (GRF glue) to the linear tear without damaging the myocardium and coronary arteries and reducing left ventricular volume. Bleeding was completely controlled. This experience suggests that this procedure might be effective for left ventricular free wall rupture.     

Size estimation method for patch used in reconstruction of LV cavity

The reconstruction of LV cavity is accomplished by suturing a patch to the viable myocardium to exclude the infarcted area from the high LV pressures. However, there is no clear guideline to estimate the size of patch used for LV reconstruction. We have designed a new method to determine the correct patch size, and applied it in 5 cases. The suture line of the patch is at the junction of contractile (functional) and infarcted portions of LV. The patch size is determined by the length of AB, termed "a", as the base, where "point A" represents the junction on the LV anterior wall side, and "point B" the junction of the LV posterior wall side, from RAO 30 degrees projection of the left ventriculogram obtained by cardiac catheterization. In LV aneurysm, we designed the patch in the range of a/2 < l < or = pi a/2, where patch length on RAO 30 degrees is considered "l". An effort was made to reconstruct to normalize LV volume and contour by designing the patch size to be a/2 < l < a, particularly when the contractile portion was enlarged by aneurysm. On the other hand, in post AMI VSD, LV contractile portion is not enlarged in early stage. Therefore, the patch was designed in the range of a < l < or = pi a/2 to maintain LV volume. Postoperative LV volume can be calculated prior to surgery, by using the lengths of the designed patch. Postoperative analysis indicated that the actual LV volume and contour were almost identical to our estimation. This method is very useful in planning the patch size for LV reconstruction.     

Minimally invasive coronary artery bypass grafting without cardiopulmonary bypass

To determine the feasibility and the effectiveness of minimally invasive direct coronary artery bypass without cardiopulmonary bypass (MICABG) in patients with left anterior descending (LAD) coronary artery disease, we evaluated 90 consecutive patients who underwent MICABG at the University Hospital of Groningen. PATIENTS: Between January 1995 and December 1996, 50 patients (mean age 60 +/- 10.3 years) with documented myocardial ischemia and isolated stenosis of the LAD were selected for MICABG. Patients with any associated cardiac disease or with acute or evolving myocardial infarction were excluded. METHODS: A small left antero-lateral thoracotomy in the 5th intercostal space was made in all patients, anastomosing the left internal mammary artery (LIMA) to the LAD. A short-term (3 days) postoperative rehabilitation programme was used. Emotional stress (STAY-DY-1 score), wound pain (VAS: visual analogue score) and O2-saturation after a 6 min walking test were measured during hospitalisation and at the first follow-up examination (2.5 week after discharge). RESULTS: Mean operative time was 92 +/- 25 min (range 60-170). We recorded 1 (1.1%) in-hospital death and three cases (3.3%) of perioperative myocardial infarction. In two cases the MICABG was converted to the midline sternotomy. One patient underwent urgent reoperation on postoperative day 1 via midline sternotomy. Mean hospital stay was 4.4 +/- 2 days. Emotional stress was significantly reduced during and after hospitalisation, compared with the admission day. Wound pain was mild (3.5/10 VAS) on postoperative day 1 and reduced significantly during hospitalisation and at first follow-up examination. O2-saturation after a 6 min walking test had significantly improved at the first follow-up examination. CONCLUSION: These results indicate that MICABG is feasible and effective in patients with LAD stenosis and leads to a fast psycho-physical recovery.     

Peripheral blood granulocytes and mononuclear cell responses in monkeys with experimental shigellosis

Between January 1992 and November 1992, four consecutive patients (ages 53 to 81 years) underwent early surgical repair of postinfarction ventricular septal ruptures using a new simple operative technique. The principles of the technique are longitudinal incision of the infarcted left anterior ventricular wall, placement of a saccular patch of single equine pericardium that covers the infarcted left ventricular wall, and large buttressed suture closure of the left ventriculotomy. The infarcted septum and infarcted left ventricular wall are completely separated from the left ventricular cavity. In this procedure, the infarcted myocardium is not resected, and left and right ventricular muscles are preserved. This technique is simple and safe for use in the acute phase of myocardial infarction, and it preserves ventricular function after surgery.     

Dartmouth Medical School bicentennial

To investigate the regulation of cell-to-cell coupling in myocardial ischaemia, the three-dimensional expression of connexin43 (Cx43) during experimental ischaemia was examined using a confocal laser scanning microscope. After induction of myocardial infarction in rats, serial optical sections were obtained from the left ventricular myocardium at various times (3 h to 60 days after ligation). The expression of Cx43 was detected immunohistochemically with FITC-labelled anti-rat Cx43 antibody. Fluorescent dots of Cx43 remained along the intercalated disc and decreased in number around the infarct up to 12 h after ligation. Cx43-expression disappeared completely within 48 h after ligation. After day 4, and especially on days 8 and 15 after ligation, the edges of the cardiomyocytes bordering the infarcted area manifested numerous sarcoplasmic tentacles that reacted positively to anti-desmin antibody. Distinct expression of Cx43 was observed extensively on the tentacles, although no cardiomyocytes remained viable around them. By day 60 after ligation, atypical expression of Cx43 had disappeared. These findings suggest that ischaemia induces temporally abnormal expression of Cx43, which might be responsible for abnormal conduction around the infarct.     

Survival of a patient with postinfarction ventricular septal defect following venoarterial bypass with centrifugal pump and reoperation for residual shunt

A 61-year-old man was hospitalized because of circulatory collapse due to postinfarction ventricular septal defect. As his hemodynamic condition deteriorated despite intraaortic counterpulsation, he underwent patch closure of VSP and patch reconstruction of the anterior left ventricular wall concomitant with coronary artery bypass grafting to the circumflex lesion immediately after admission. Femorofemoral circulatory assist with centrifugal pump was necessitated to wean from cardiopulmonary bypass because of severe left ventricular dysfunction. Circulatory assist was controlled to maintain mixed venous oxygen saturation of more than 70% under mild hypothermia. On the second postoperative day (POD), increased oxygen saturation from right atrium to pulmonary artery developed (Qp/Qs = 2.1). Further surgery was performed on an emergency basis for additional patch closure of VSP. Then he was successfully weaned from cardiopulmonary bypass successfully. The patient was extubated on the 14th POD and was ambulatory when he discharged on the 56th POD. Immediate surgical intervention should be performed for the patient with postinfarction ventricular septal defect when the hemodynamic state deteriorates under intraaortic counterpulsation.     

Mitral valve replacement and coronary artery bypass grafting for postinfarction mitral papillary muscle rupture

A 79-year-old man was admitted to our hospital with heart failure following acute inferior myocardial infarction. An echocardiogram demonstrated severe mitral insufficiency, and coronary arteriography revealed double vesel disease. Following diagnosis of ischemic papillary muscle dysfunction, PTCA was performed, but the mitral insufficiency was not eliminated. Follow-up echocardiography disclosed rupture of the posterior papillary muscle. He underwent surgery on the 30th day after onset of acute myocardial infarction. Partial rupture of the posterior papillary muscle was found at surgery, and mitral valve replacement and single coronary artery bypass to Lcx were performed. His postoperative course was uneventful, and he was discharged on the 46th day after operation.     

Myocardial infarction and regulatory myosin light chain

Myosin from cardiac muscle consists of two heavy chains and two pairs of light chain. Regulatory myosin light chain (RMLC) is phosphorylated by a Ca2+ and calmodulin dependent myosin light chain kinase. The impact of experimental myocardial infarction on cardiac RMLC was studied. The left anterior descending coronary artery of rabbits was ligated. Three, 7 and 14 days later the animals were euthanized, sections of the heart were frozen in liquid nitrogen and later subjected to 2-dimensional electrophoresis. Isoelectric focusing was carried out at a pH range of 4.5-5.4. Reproducible patterns of protein separation showed four spots with proteins of phosphorylatable regulatory light chains shifted to a more negative pH as compared to essential light chain. We investigated changes in phosphorylation of RMLC in infarcted heart muscle. As compared to sham operated animals, a decline in phosphorylation of RMLC was present in both infarcted and non-infarcted portions of the left ventricle; the latter was significant 7 days following the onset of ischemia. In contrast, the decline in percent phosphorylation in the infarcted area was not significant. The amount of RMLC decreased significantly in the infarcted portion. A highly significant reduction in the percent of viable cardiomyocytes accompanied the decline in phosphorylation. There was a significant correlation of RMLC following administration of isoproterenol, 7 and 14 days following onset of ischemia. Only faint traces of essential atrial myosin light chain (ALC-1) were present in the non-infarcted portion of the left ventricle. No correlation was found between percent phosphorylation and the amount of RMLC (density) following infusion of saline or isoproterenol. Isoproterenol significantly increased percent phosphorylation without altering the amount of RMLC protein. We conclude that myocardial infarction profoundly affects regulatory myosin light chain phosphorylation in the infarcted and non-infarcted areas of the myocardium and that RMLC plays a significant part in myocardial contractility.     

Intrathecal administration of triamcinolone in treatment of pain after discectomy

The efficacy and compatibility of intrathecal corticoid therapy was studied in a series of 160 patients (out of a total collective of 3000 patients operated on over a 5-year period for disc herniation) suffering from continuing pain in the first 5 days following discectomy. 80 patients received triamcinolone acetonide in crystalline suspension (Volon A 80, 2.0 ml) intrathecally via lumbar puncture on the 5th postoperative day (group A). The remaining 80 patients acted as controls (group B). Additionally, all patients were treated by conservative means. On the 6th, 8th and 12th postoperative day they all had to classify their wellbeing according to a 5-grade pain scale. On the 6th day 75% of group A patients assessed their symptoms as belonging to the favourable grades 1 and 2 (completely free of pain or slight remaining complaints), whereas only 5% of the control group did so (p < 0.0003). On the 8th and 12th postoperative day this difference was not as significant. All patients were examined again 4 weeks after discharge from the hospital. At this time the difference between the two groups was not statistically significant (p < 0.12). No general systemic effects due to intrathecal corticoid administration were recorded. However, in 11 cases (13%) postpunctional signs of greater or lesser severity, reaching from slight to severe headache with nausea and vomiting occurred. All these symptoms disappeared at the latest within 1 week and would--in our opinion--be avoidable by correct lumbar puncture technique. In general, this study revealed that intrathecal triamcinolone administration is highly effective in the relief of postdiscectomy pain and may reduce the period of postoperative pain significantly.     

Apoptosis in experimental myocardial infarction in situ and in the perfused heart in vitro

We report the appearance of apoptotic cells in experimental myocardial infarction (rabbit heart) in in situ and in vitro preparations. Apoptosis was recognized by intravital staining with Hoechst 33342 (Ho342), by nick-end labeling (TUNEL) and by DNA laddering. A steady rise in the relative number of apoptotic cardiomyocytes (apoptotic index) was noted in in situ preparations. Apoptosis was first noted 6 h after the onset of ischemia with its highest value occurring after 72 h. Apoptotic nuclei were absent in remote areas of the left and right ventricles. Apoptotic nuclei within the infarcted area showed diminished intensity of Ho342 fluorescence. Three days after ischemia, a border zone adjacent to the infarcted area consisting of apoptotic macrophages was recognized. A novel finding was the appearance of apoptotic cardiomyocytes in the isolated perfused ischemic heart. Occurring as early as 50 min after the onset of ischemia, a high apoptotic index was present adjacent to the ligature placed around the coronary artery. This observation provides the opportunity to selectively examine factors leading to apoptosis in the ischemic heart under controlled experimental conditions.     

Nonsurgical infarctectomy in acute experimental myocardial infarction

This study examines whether a catheter mounted left intraventricular balloon may prevent left ventricular (LV) dysfunction following acute experimental myocardial infarction. In 10 anesthetized pigs, multiple coronary arterial ligations were applied around the apex of the heart. LV end-diastolic pressure (LVEDP), aortic flow (AF), and LV long and short axis fractional shortening (FS) were measured before and at 15 min intervals after ligations. At the 60th min after ligation, the LV long axis FS and AF decreased by 7.2 +/- 2.6% (p < 0.05) and 13.25 +/- 2.68% (p < 0.01), respectively, and the LVEDP increased by 4.3 +/- 1.1 mm Hg (p < 0.01) while no change was noted in the LV short axis FS. An intraventricular catheter mounted nonpulsating balloon was positioned over the endocardium of the infarcted area at the LV apex. Inflation of the nonpulsating balloon to an optimal volume, which was found to be equal to 8-10% of the LV end-diastolic volume, resulted in a reduction (by 3.8 +/- 1.2 mm Hg, p < 0.01) of the already increased LVEDP and in an increase (by 6.6 +/- 2.1%, p < 0.05) in the LV short axis FS while no statistically significant change was noted in the AF and LV long axis FS. It is concluded that an intraventricular catheter mounted balloon patch positioned over the endocardium of the infarcted area may ameliorate early LV dysfunction, possibly by interfering with the functional geometry of the LV contraction.     

Sustained decrease in brain regional blood flow after microsphere embolism in rats

BACKGROUND AND PURPOSE: An experimental model that induces sustained ischemia and infarction may provide useful information relevant to prevention of the development of ischemic brain disease. The purpose of the present study was to elucidate the pathophysiological consequences of cerebral blood flow under sustained cerebral ischemia or oligemia and infarction in rats after microsphere embolism. METHODS: We injected 900 microspheres (48 microns in diameter) into the right internal carotid artery of 146 rats and determined the time course of changes in blood flow of the cerebral cortex, striatum, and hippocampus of both hemispheres by the hydrogen clearance method for a period of 28 days after the operation. Infarct area was determined by triphenyltetrazolium chloride staining and hematoxylin and eosin staining methods. RESULTS: Cortical and striatal blood flow of the right hemisphere of microsphere-injected rats was significantly decreased after the embolism, and this was sustained throughout the experiment. Hippocampal blood flow of the microsphere-injected hemisphere was also decreased on days 1 and 3 but tended to return toward control levels thereafter. In the left hemisphere, reduction in regional blood flow was detected in the cortex and hippocampus on day 1 and the striatum on day 3. A triphenyltetrazolium chloride-unstained area had developed by day 3 after the embolism. The extent of the area was similar to that on days 7 and 28. Microscopic examination revealed degenerative areas scattered mainly in the parietotemporal cortex, corpus callosum, hippocampus, thalamus, and lenticular nucleus of the embolized hemisphere, demonstrating the induction of widespread necrosis after embolism. CONCLUSIONS: Microsphere embolism resulted in a sustained decrease in regional blood flow and production of cerebral infarction in the brain regions of the microsphere-injected hemisphere.     

Induction of apoptosis in myocardial infarction and its possible relationship to nitric oxide synthase in macrophages

Activated macrophages produce nitric oxide through the inducible form of nitric oxide synthase (iNOS). Previously, a significant increase of iNOS activity in macrophages in infarcted rabbit heart tissue was observed. The present study is concerned with the induction of apoptosis in macrophages and cardiomyocytes in infarcted rabbit heart tissue. The left anterior descending artery of rabbits was ligated. The heart was excised five hours, one, two, three, ten and twenty days later, and DNA was extracted from infarcted and non-infarcted region and subjected to electrophoresis. Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) was carried out, and iNOS activity was measured by conversion of L-[14C]-arginine to L-[14C]-citrulline. Positive staining by TUNEL was seen in some cardiomyocytes five hours after coronary ligation and on postoperative day (POD) 1; internucleosomal DNA fragmentation was not noted. On POD 2 and 3, many infiltrating cells, immunohistochemically identified as macrophages, were positively stained by TUNEL; DNA fragmentation was also present. Apoptosis was not found on POD 10 and 20. The peak activity of iNOS was noted on POD 3, which corresponded with the induction of apoptosis. It is tempting to speculate that a causal relationship exists between increased iNOS formation and induction of apoptosis in macrophages in infarcted rabbit heart tissue.     

Effects of extensive oral surgery and hemorrhage on coagulation and fibrinolysis

The changes in coagulation and fibrinolytic activity in 22 patients with oral cancer undergoing extensive surgical procedures were studied. The patients were divided into two groups: group I patients suffered blood loss of less than 2,000 mL and group II patients had blood loss of more than 2,000 mL. The platelet count decreased significantly during surgery, at the end of surgery and on the 1st postoperative day in both groups. Fibrinogen was decreased during and at the end of surgery in both groups, but increased significantly on the 3rd postoperative day and reached about two times the preoperative levels on the 7th postoperative day. Fibrin degradation products increased significantly after surgery and reached the maximum value on the 1st postoperative day in both groups. Plasmin inhibitor complex and plasminogen increased significantly on the 3rd and 7th postoperative days. There was no clear evidence regarding the influence of blood loss on coagulation and fibrinolytic factors except for platelets. It was concluded that coagulation and fibrinolysis are enhanced between the 3rd and 7th postoperative days.     

The effects of metyrapone (Metopiron) on the half-life time of phenazone (Antipyrine) in rabbits

The literature concerning perforation and imminent perforation of the caecum is reviewed. The greatest importance is attached to 5 cases of perforation of the caecum associated with paralytic ileus following Caesarean section. The caecal diameter was determined by radiography in 100 patients on the 3rd and 5th day after Caesarean section. At the same time the volume of subdiaphragmatic free gas was assessed. An average caecal diameter of 6.4 cm was found, which is not different from the findings in the normal population. Increasing caecal diameter during the puerperium gives rise to suspicion of the caecum. In 90% of the patients free subdiaphragmatic gas disappeared by the 5th day after Caesarean section.     

Functional evaluation of the shoulder after surgical and nonsurgical treatment of grade III acromio-clavicular dislocation

Fecal specimens from a baby vaccine were collected every day from 1 to 51 days after primary vaccination and from 0 to 15 days after secondary vaccination. Polioviruses were isolated with GMK-2 cell line from 10% emulsion of the feces and titrated the virus contents in the emulsion of the feces. The isolated viruses were tested the reproductive capacity at 39.0 degrees C and 39.5 degrees C by the plaque method with primary cynomologous monkey kidney cells. Viruses were isolated from the feces during 28 days for type 1, 39 days for type 2 and 36 days for type 3 after primary vaccination, however, only type 1 viruses were isolated during 7 days after secondary vaccination. The multiplication of type 3 viruses in the intestine were increased after diminished the multiplication of type 1 and type 2. In plaque formation capacity at 39.0 degrees C and 39.5 degrees C, the isolates had shown to differ clearly among the types of poliovirus. After primary vaccination, type 1 isolates were not produced the plaques at 39.0 degrees C and 39.5 degrees C. Although type 2 isolates were not formed the plaques until the 14th day at 39.5 degrees C, the plaque formation capacity of the these isolates were increased gradually i.e.; on the 20th day (10(0.88) PFU/ml), the 26th day (10(2.00) PFU/ml) and the 39th day (10(2.63) PFU/ml) at 39.5 degrees C, and all of type 2 isolates tested were showed the plaque formation capacity (10(2.88 approximately 10(3.76) PFU/ml) at 39.0 degrees C. Type 3 isolates were formed plaques at 39.0 degrees C and 39.5 degrees C from the 7th day. After the secondary vaccination, type 1 isolates (7th day) was a little changed them. Neutralizing antibody titers were shown that type 1 was 320, type 2 was 110 and type 3 was 60 after 1 year of the second administration. These titers were closely similar the geometric mean titers of 2 year old babies in Japan.