Neurohormonal response to left ventricular reconstruction surgery in ischemic cardiomyopathy

OBJECTIVES: Activation of the neuroendocrine axis in congestive heart failure is of prognostic significance, and neurohumoral blocking therapy prolongs survival. The hypothesis that surgical reduction of left ventricular size and function decreases neuroendocrine activation is less established. We evaluated the neurohormonal response to left ventricular reconstruction surgery in ischemic cardiomyopathy. METHODS: Norepinephrine, plasma renin activity, and angiotensin II were measured in 10 patients before and 12 months after left ventricular reconstruction. In an additional 5 patients, brain natriuretric peptide was measured before and 3 months postoperatively. Three-dimensional cardiovascular imaging was used to assess ejection fraction and left ventricular end-diastolic volume index. RESULTS: Concurrent with improvements of New York Heart Association functional class (2.9 +/- 0.5 preoperatively vs 2.0 +/- 0.4 postoperatively, P <.001), ejection fraction (23.9% +/- 6.6% vs 36.2% +/- 6.2%, P <.01), and left ventricular end-diastolic volume index (140.8 +/- 33.8 mL/m(2) vs 90.6 +/- 18.3 mL/m(2), P <.01), considerable reductions were observed for median plasma profiles of norepinephrine (562.0 pg/mL vs 319.0 pg/mL, P <.05), plasma renin activity (5.75 microg/L/h vs 3.45 microg/L/h, P <.05), angiotensin II (41.0 ng/mL vs 23.0 ng/mL, P =.051), and brain natriuretric peptide (771.0 pg/mL vs 266.0 pg/mL, P <.05). The more plasma renin activity or angiotensin II decreased after left ventricular reconstruction, the higher was the increase in ejection fraction (R = -.745, P <.05 [plasma renin activity]; R = -.808, P <.05 [angiotensin II]). CONCLUSIONS: Surgical improvements of ejection fraction and left ventricular end-diastolic volume index by left ventricular reconstruction were accompanied by improvement of both the neuroendocrine activity and the functional status in patients with congestive heart failure. Whether this favorable neurohormonal response is predictive of an improved survival requires further evaluation.     

Nevoid Basal cell carcinoma syndrome with medulloblastoma and meningioma--case report

A 35-year-old man presented with a rare case of nevoid basal cell carcinoma syndrome, or Gorlin's syndrome, associated with both medulloblastoma and meningioma, manifesting as visual field constriction due to multiple parasellar tumors. He had undergone resection of a medulloblastoma at the age of 1 year 9 months, followed by adjunctive irradiation with a total dose of 40 Gy. He presented with multiple subcutaneous nodules on his face and neck. Histological examination of biopsy specimens established the diagnosis of nevoid basal cell carcinoma syndrome. Tuberculum sellae meningioma was removed through a craniotomy, and his symptoms improved. Meningioma is known to occur in the field of therapeutic irradiation, so chemotherapy may be a better option for medulloblastoma associated with nevoid basal cell carcinoma syndrome.     

Comparison of the effects of angiotensin II receptor antagonist monotherapy and combination therapy with a diuretic on cardiac function in spontaneously hypertensive rats

Objective

Losartan, an angiotensin II receptor blocker (ARB), has been reported to promote sodium excretion and show an enhanced antihypertensive effect when used in combination with hydrochlorothiazide (HCTZ). We investigated the effects of losartan monotherapy and combination therapy together with HCTZ on cardiac function in hypertensive rats using echocardiography.

Methods

Spontaneously hypertensive rats (n?=?21) fed on high-salt diet (8?% NaCl) for 13?weeks were randomly assigned to rats without medication (HS, n?=?7), those medicated with ARB (ARB, losartan 30?mg/kg/day, n?=?8), and those with ARB and HCTZ (ARB?+?HCTZ, losartan 30?mg/kg/day?+?HCTZ 10?mg/kg/day, n?=?6). Blood pressure measurements and echocardiography were performed at 13, 17, and 29?weeks of age. After the end of the protocol, the proportion of cardiac muscle fibrosis was measured histologically.

Results

In the HS group, blood pressure and left ventricular mass/body weight (LV mass/BW) increased, and % fractional shortening (%FS) and early diastolic mitral annular velocity (e??) decreased significantly with age. In the ARB group, although blood pressure and %FS were maintained, LV mass/BW increased with age as in the HS group, and e?? decreased. In the ARB?+?HCTZ group, blood pressure decreased and LV mass/BW, %FS, and e?? were maintained. The progression of myocardial fibrosis was clearly prevented in rats treated with ARB.

Conclusion

ARB was shown to inhibit systolic disorder and myocardial fibrosis in hypertensive rats. Combination therapy proved to be more effective than monotherapy and is also effective in inhibiting diastolic disorders.     

Transumbilical approach for laparo-endoscopic single-site adrenalectomy: initial experience and short-term outcome

Objectives: To report our initial experience with transumbilical laparo‐endoscopic single‐site adrenalectomy for adrenal tumors by using a single port with a multichannel cannula and bent laparoscopic instrumentation. Methods: Between December 2009 and December 2010, 30 patients underwent transumbilical laparo‐endoscopic single‐site adrenalectomy at our hospital. The procedure was carried out for adrenal cortical adenoma in 17 patients, adrenal pheochromocytoma in seven patients and other types of tumors in six patients. A multichannel port, bent laparoscopic instruments and Opti4 laparoscopic electrodes were used in all patients. The intraperitoneal space was approached through the umbilicus. The multichannel port was placed through a 2‐cm incision at the inner edge of the umbilicus. A 5‐mm flexible laparoscope was introduced to maintain an adequate laparoscopic view, and surgical specimens were extracted using an Endocatch bag. Results: All procedures were successfully completed, with only one incision through the umbilicus, and without conversion to a standard laparoscopic approach. Mean operative time was 120.1 ± 34.7 min. Tumor laterality and patient body mass index did not affect surgical morbidity. The initial 15 patients had a significantly longer mean pneumoperitoneum time (95.8 ± 37.5 min) than the last 15 patients (70.5 ± 18.7 min). Only one postoperative complication was observed (postoperative hematoma). Conclusions: A transumbilical approach for laparo‐endoscopic single‐site adrenalectomy is safe and feasible, and it results in superior cosmesis. Improvements in surgical devices might facilitate further development of this approach.     

The impact of repeated subclinical acute rejection on the progression of chronic allograft nephropathy

Chronic allograft nephropathy (CAN) is due to both immunologic and non-immunologic factors and results in the development of nonspecific pathologic features that may even be present in long-term well-functioning renal allografts. To investigate the natural history of CAN and potential risk factors associated with progression of these histologic lesions, this study evaluated the of histologic alterations of 124 sequential protocol biopsies performed at 2, 3, and 5 yr after transplantation in 46 patients who exhibited histologic evidence of CAN in the 1-yr biopsy. The occurrence of late acute rejection (AR) greater than 4 mo posttransplant was significantly associated with the development of histologic CAN. In contrast, early clinical AR occurring within 3 mo had no impact on the subsequent development of CAN at 1 yr. Subclinical AR was evident in association with CAN in 50%, 32%, 19%, and 16% of cases with CAN at 1, 2, 3, and 5 yr, respectively. These acute lesions correlated significantly with histologic progression defined as an increased CADI score of the follow-up biopsies. Furthermore, a group of patients who exhibited repeated subclinical AR in the sequential follow-up biopsies had a lower creatinine clearance at 5 yr after transplantation and worse long-term graft survival. In contrast, the absence of evidence of acute inflammation in association with CAN at any time point was associated with minimal deterioration in renal function or progression of renal lesions during the observation period. These results suggest that the persistence of chronic active inflammation may be responsible for the histologic progression of CAN.     

Endovascular repair of a presumed aortoduodenal fistula.

This report describes the use of transluminal endovascular grafting for the treatment of a presumed aortoduodenal fistula. The patient was a 71-year-old man who had undergone resection and graft replacement for an abdominal aortic aneurysm. Three years after operation, melena was caused by perforation of the duodenal wall by a pseudoaneurysm at the proximal graft anastomosis. The pseudoaneurysm was treated by transluminal endovascular grafting. The pseudoaneurysm was subsequently thrombosed and absorbed. The ulcer-like lesions at the site of the duodenal wall perforated by the pseudoaneurysm also resolved. Endovascular stent-grafts may have a role to play in management of aortoduodenal fistula.     

Human Clinical Fitting Study of the DexAide Right Ventricular Assist Device

The DexAide right ventricular assist device (RVAD) has been developed as an implantable RVAD. The purpose of this study was to determine the final design and optimal anatomical placement of the DexAide RVAD when implanted simultaneously with either of two commercially available left ventricular assist devices (LVADs) in patients. A mock-up DexAide RVAD was used to assess configuration with each of two types of commercially available LVADs at the time of LVAD implantation in three human clinical cases. The pump body of the DexAide RVAD was placed either in the preperitoneal space or in the right thoracic cavity. The DexAide RVAD placed into the right thoracic cavity is suitable for use with the Novacor or HeartMate II LVADs. The results of this study will guide the finalization of the inflow cannula and optimal placement of the DexAide RVAD for human clinical trials.     

Microsurgical anatomy of cerebral revascularization. Part I: anterior circulation

OBJECT: Revascularization is an important component of treatment for complex aneurysms that require parent vessel occlusion, skull base tumors that involve major vessels, and certain ischemic diseases. In this study, the authors examined the microsurgical anatomy of cerebral revascularization in the anterior circulation by demonstrating various procedures for bypass surgery. METHODS: Twenty-five adult cadaveric specimens were studied, using 3 to 40 magnification, after the arteries and veins had been perfused with colored silicone. The microsurgical anatomy of cerebral revascularization in the anterior circulation was examined with the focus on the donor, recipient, and graft vessels. The techniques discussed in this paper include the superficial temporal artery (STA)-middle cerebral artery (MCA), middle meningeal artery (MMA)-MCA, and side-to-side anastomoses; short arterial and venous interposition grafting; and external carotid artery/internal carotid artery (ICA)-M2 and ICA-ICA bypasses. Bypass procedures for cerebral revascularization are divided into two categories depending on their flow volume: low-flow and high-flow bypasses. A low-flow bypass, such as the STA-MCA anastomosis, is used to cover a relatively small area, whereas a high-flow bypass, such as the ICA-ICA anastomosis, is used for larger areas. Cerebral revascularization techniques are also divided into two types depending on the graft materials: pedicled arterial grafts, such as STA and occipital artery grafts, and free venous or arterial grafts, which are usually saphenous vein and radial artery grafts. Pedicled arterial grafts are mainly used for low-flow bypasses, whereas venous or arterial grafts are used for high-flow bypasses. CONCLUSIONS: It is important to understand the methods of bypass procedures and to consider indications in which cerebral revascularization is needed.