Usefulness of the Noncontact Mapping System to Elucidate the Conduction Property for the Treatment of Common Atrial Flutter

Background: The functional role of the cavotricuspid isthmus (CTI) for common atrial flutter (cAFL) remains to be elucidated. In the present study, we examined whether the EnSite system (St. Jude Medical, St. Paul, MN, USA), a noncontact mapping system, is useful to evaluate the conduction properties of CTI to minimize radiofrequency (RF) ablation applications for cAFL. Methods: We enrolled 22 consecutive patients with cAFL (64.1 ± 9.5 years old, M/F 21/1) treated with the EnSite system and examined the conduction properties during cAFL and during atrial pacing. In addition, the effectiveness of the system was evaluated in comparison with the conventional ablation group (67 ± 8.9 years old, n = 15, M/F 13/2). Result: In 11 out of the 22 patients, CTI block line was achieved by fewer RF applications on a presumed single activation pathway which the EnSite system showed (point ablation [PA] group), and the remaining 11 patients needed additional linear ablation (additional ablation [AA] group). The number of RF applications in the PA group was significantly smaller than that in the conventional group. During the lower lateral right atrial pacing at a cycle length of 600 ms, the CV of the CTI in the PA group was smaller compared to that in the AA group (1.36 ± 0.61 vs 2.17 ± 0.66 m/s, P < 0.05), although the CV during cAFL (averaged cycle length 245 ± 34 ms) was not different in both groups. Conclusions: These results indicate that targeting the presumed single line identified by EnSite could be an optional therapy for cAFL RF ablation, and diverse conduction properties in CTI are related to the success rate of this procedure. (PACE 2012;35:1464–1471)     

Spontaneous recovery from renal infarction resulting from renal artery dissection

A 31-year-old, previously normotensive healthy man developed right flank pain and was admitted to a medical service. Right renal infarction was suspected by enhanced abdominal computed tomography (CT) and arteriography. Fourteen days after the onset, he was transferred to the Oita University Hospital, Oita, Japan. Renal angiography revealed an isolated renal artery dissection causing renal atrophy due to main stem narrowing of the right renal artery. Renogram and renal scintigram with (99m)Tc-diethylene triamine pentaacetic acid revealed a remarkable decline in the glomerular filtration rate and almost no uptake in the right kidney. Four months later, in spite of our belief that functional recovery could not be expected, intravenous pyelography and enhanced abdominal CT scans revealed a functioning right kidney that had spontaneously recovered from the renal artery dissection through conservative management.     

Long-term prognosis and prognostic factors of liver cirrhosis in the 1980s

Abstract The prognosis of 174 patients with cirrhosis during the 1980s (1981–89) was analysed. The estimated survival rates were 87.3% in 3 years and 68.5% in 5 years. During the follow-up period, 58 patients died: 20 of hepatocellular carcinoma (37.7%); 11 of hepatic failure (20.8%); eight of gastrointestinal bleeding (15.1%); and 14 of other causes (26.4%). Multivariate analysis revealed that serum albumin, indocyanine green retention rate at 15 min and white blood cell count were significantly associated with prognosis. The results were also compared to our previous study covering the 1970s (1971–80). The estimated survival rate was significantly improved compared to that during the 1970s (54.3% in 5 years, P < 0.001). In the 1980s, hepatic failure mortality significantly decreased ( P < 0.01), and non-liver-related mortality significantly increased ( P < 0.05). In summary, the prognosis of cirrhosis has improved in recent years, and changes of death cause and prognostic factors were observed. It was concluded that to evaluate the severity and prognosis of cirrhosis, new indices and appropriate classification were necessary.     

Mexiletine Has No Effect on Defibrillation Energy Requirements in Dogs

Many of the antiarrhythmic drugs produce a rise in the ventricular defibrillation threshold (DFT). Although mexiletine has also been reported as the probable cause of a significant elevation of DFT, there has been no previous study; therefore, the effect of mexiletine on DFT was investigated in the present study. The experiments were performed on ten mongrel dogs in the open-chest state using general anestbesia. Mexiletine 1,2,4, 6, or 8 mg/kg was administered as the loading dose, followed by the same dose/kg per hour. In these five groups, fibrillation/defibrillation (F/D) trials were performed repeatedly every 10 minutes, until 60 minutes after starting the maintenance dose. F/D trials were also performed at 30, 45, and 60 minutes after the completion of mexiletine infusion. The heart was allowed to fibrillate for a total of 30 seconds. Applying internal paddles to the beart, energies of 2, 3, 5, 7, 10, 20, and 30 J maximum were used. The minimal energy shock that caused defibrillation was defined as the DFT. The mexiletine concentration in each group cbanged from 0 to 6.11 μg/mL, DFT ranged from 2–10 J, and no statistical correlation was found between mexiletine concentration and DFT. We conclude that mexiletine does not induce an increase in DFT in dogs.     

Liver abscess that developed after a long interval of transcatheter arterial embolization followed by formation of hepatoduodenal fistula

A 55‐year‐old male patient with hepatocellular carcinoma underwent transcatheter arterial embolization (TAE). He became febrile and experienced pain at the right hypochondrial region 323 days later, which led to the discovery of a liver abscess that fistulated into the duodenal bulb. There have been no reports on the fistulation of liver abscesses into the digestive system following TAE. Rhodococcus equi was isolated as a causative agent, which distinguished the case further.     

Infection-induced urethral defect treated by urethral reconstruction with a radial forearm flap

Abstract A 47-year-old man was admitted with the chief complaint of a urethral defect. An approximately 17-cm defect of the urethra seemed to have been occurred by the infection of implanted foreign bodies in the penile skin. Reconstruction of the urethra and the ventral skin was performed with a free radial forearm flap. A fistula formed at the proximal anastomosis after the operation, but was controlled conservatively. Urethral stricture at the proximal anastomosis subsequently developed. A urethral stent made of shape memory alloy was placed with the preservation of voiding function.     

ETHANOL INDUCES HETEROGENEOUS REDUCTION OF CYTOCHROME aa3 WITHIN PERFUSED RAT LIVER LOBULE ASSESSED USING MICROSPECTROSCOPY

The redox state of cytochrome aa₃ was measured at microspots(20µm diameter) within the lobule of perfused rat livers,using reflectance microspectroscopy, and the effect of ethanolinfusion on sublobular distribution of the redox states wasevaluated. A sigmoidal relationship was observed between oxygendelivery and the reduction of cytochrome aa₃ in both the periportaland pericentral regions of the liver lobule when the influentO₂ concentration was decreased in a graduated manner. This sigmoidalcurve was shifted to the more reduced state by ethanol infusion,with ethanol (25–100mM) increasing the degree of cytochromeaa₃ reduction in a dose-dependent manner according to the distancefrom the periportal region along a sinusoid. This increase wasspatially heterogeneous within a liver lobule. These data indicatethat ethanol accelerates cytochrome aa₃ reduction, with a distinctgradient of reduction along sinusoids but a heterogeneous distributionwithin the liver lobule.     

Extensive lymphadenectomy for thoracic esophageal carcinoma: A two-stage operation for high-risk patients

Extensive lymphadenectomy (ELA) for esophageal carcinoma has always been limited to low-risk patients; however, we have developed a two-stage operation which extends the indications for ELA to include certain high-risk patients. Of 70 patients who underwent transthoracic subtotal esophagectomy for thoracic esophageal carcinoma between 1986 and 1991, 48 qualified for ELA which was performed on 45, including 27 low-risk patients (group A) whom underwent the traditional one-stage operation, while 18 high-risk patients underwent the two-stage operation (group B). The number of hospital deaths and postoperative complications was similar between the two groups. The median survival was 26 months in group B and 17 months in group A. The 40-day delay in resection of the neck and abdominal nodes in the two-stage operation did not significantly affect lymph node metastases, postoperative recurrence, or long-term survival. Thus, the two-stage operation is an oncologically meaningful approach to the treatment of high-risk patients who present with thoracic esophageal carcinoma.     

Peritoneoscopic Findings of Autoimmune Hepatitis

Abstract: To clarify the morphologic differences between hepatitis C virus (HCVI-negative autoimmune hepatitis (AIH) and HCV-positive AIH, peritoneoscopic findings were studied. Among twenty three patients with AIH according to the Japanese criteria (1992), 15 were HCV-negative and 8 were HCV-positive. The terms grooved depression, coarse depression, coarse elevation, coarse undulation, and round-shaped reddish marking (RM) were used in this study to evaluate the peritoneoscopic findings. Grooved depressions, coarse depressions, coarse elevations, coarse undulations and round-shaped RMs were all common findings (53%, 87%, 73%, 80%, and 80%, respectively) in HCV-negative AIH patients, but they were less common (13%, 25%, 13%, 13%, and 0%, respectively) in HCV-positive AIH patients. This study revealed that HCV-negative AIH patients had different peritoneoscopic findings from HCV-positive AIH patients. Thus HCV-negative AIH may be typical AIH, and HCV-positive AIH may essentially be a subset of type C chronic hepatitis.