Changes in left anterior descending coronary artery flow profiles after coronary artery bypass grafting examined by means of transthoracic Doppler echocardiography

OBJECTIVE: We sought to investigate the changes of velocity profiles in the left anterior descending coronary artery after coronary artery bypass grafting using transthoracic Doppler echocardiography. METHODS: Forty-five patients who received a bypass graft to the left anterior descending coronary artery were studied. Before coronary artery bypass grafting, Doppler velocity profiles of the distal left anterior descending coronary artery were recorded with transthoracic Doppler echocardiography. Peak systolic velocity, mean systolic velocity, peak diastolic velocity, mean diastolic velocity, total velocity time integral, systolic velocity time integral, and diastolic velocity time integral were measured. Three weeks after coronary artery bypass grafting, left anterior descending coronary artery antegrade flow in the distal portion of the anastomosis was obtained by using the same method. Coronary angiography was performed before and 3 weeks after coronary artery bypass grafting. RESULTS: The overall success rate of measuring the left anterior descending coronary artery flow was 60.0% preoperatively and 80.0% postoperatively. In 25 patients, in whom all parameters were obtained both before and after coronary artery bypass grafting, the following increased significantly after coronary artery bypass grafting: peak systolic velocity (14.86 +/- 7.50 vs 25.07 +/- 17.02 cm/s, P =.0045), mean systolic velocity (9.86 +/- 5.42 vs 18.03 +/- 12.94 cm/s, P =.0026), peak diastolic velocity (24.26 +/- 12.54 vs 48.28 +/- 31.66 cm/s, P =.0021), mean diastolic velocity (14.94 +/- 6.65 vs 30.36 +/- 20.71 cm/s, P =.0022), diastolic velocity time integral (7.22 +/- 2.88 vs 15.55 +/- 10.39 cm, P =.0009), total velocity time integral (10.50 +/- 4.48 vs 19.27 +/- 12.63 cm, P =.0034), and diastolic-to-systolic velocity time integral ratio (3.09 +/- 1.53 vs 4.97 +/- 2.75, P =.0044). Angiography showed graft patency and no significant change in left anterior descending coronary artery stenosis in all patients. CONCLUSIONS: Transthoracic Doppler echocardiography showed a significant increase in some parameters in left anterior descending coronary artery flow after coronary artery bypass grafting. Measurement of left anterior descending coronary artery flow by means of transthoracic Doppler echocardiography might be a noninvasive method to evaluate the effect of bypass grafting on the left anterior descending coronary artery.     

Efficacy of left ventricular restoration with mitral valve surgery for endstage ischemic cardiomyopathy

Patients with ischemic cardiomyopathy (ICM) are at an extremely high risk of death and ischemic events. This study aims to evaluate the impact of left ventricular restoration (LVR) and mitral valve surgery on the cardiac and clinical functional status of the patients with ICM. Twenty-six patients (46-80 years, mean: 64 years) with severely dilated heart (left ventricular end-systolic volume index: LVESVI > or = 100 ml/m2) who had coronary artery bypass grafting (2.8+/-1.3), mitral valve surgery, and LVR were enrolled in this study. Left ventricular end-diastolic volume index and LVESVI significantly decreased (from 169+/-44 to 130+/-41 ml/m2, P=0.0005, from 120+/-33 to 89+/-43 ml/m2, P=0.0012). Left ventricular ejection fraction showed no change. MR showed significant improvement (from 2.7+/-0.6 to 1.0+/-0.4, P<0.0001) and NYHA functional class showed improvement (from 3.2+/-0.8 to 1.5+/-0.9, P<0.0001). A 5-year survival rate was 71.2%. In conclusion, this aggressive approach with LVR aiming to treat end-stage ICM by relief of ischemia, reduction of LV wall tension by decreasing LV volume and stopping mitral leak, is effective for LV volume reduction and improvement of clinical functional status.     

Impact of ostial stenosis on the Doppler flow profiles in internal thoracic artery graft.

As ostial stenoses of internal thoracic artery (ITA) grafts rarely occur after coronary artery bypass grafting, little is known about their Doppler flow profile. This report describes changes in the Doppler flow of ITA grafts with ostial stenosis after surgical repair of the stenosis. A 54-year-old male underwent coronary artery bypass grafting (CABG) in which the left ITA was anastomosed to the left anterior descending coronary artery. The follow-up coronary angiography revealed an ostial 90% stenosis of the ITA. The patient underwent elective surgery during which the radial artery was interposed between the left subclavian artery and the ITA. Intraoperative ultrasonography was performed immediately before cut down of the ITA graft and again immediately after completion of all anastomoses. Both diastolic and systolic velocities and the velocity time integral increased more than 2-fold after the repair. Neither the diastolic-to-systolic peak velocity ratio nor the diastolic velocity time integral fraction showed remarkable change. These profiles were different from those reported previously for distal stenosis.     

Coronary artery bypass grafting for left main trunk coronary artery lesion associated with essential thrombocythemia

Effort angina due to left main trunk (LMT) lesion was diagnosed in a 58-year-old man. Platelet count was markedly increased and essential thrombocythemia was also diagnosed. Because of LMT disease, coronary artery bypass grafting (CABG) was performed prior to medication for essential thrombocythemia. There were no complications during the operation or in the early postoperative period. Melphalan was administered postoperatively resulting in the decrease of platelet count. Postoperative coronary angiography demonstrated that both grafts were patent; however, immediately after coronary angiography, the patient suffered from a sudden onset of myocardial infarction and cerebral infarction. The therapeutic problems associated with hematological disorder in such patients are discussed in this report.     

Effects of levetiracetam on seizure frequency and neuropsychological impairments in children with refractory epilepsy with secondary bilateral synchrony

PurposeIn epilepsy with continuous spikes and waves during slow sleep (CSWS), which is a representative epileptic syndrome of secondary bilateral synchrony (SBS), the urgent suppression of this electroencephalographic (EEG) abnormality may be necessary to prevent the progression of neuropsychological impairments. The purpose of this study was to determine the efficacy of levetiracetam (LEV) on SBS, seizure frequency, and neuropsychological impairments in children with refractory epilepsy.MethodsEleven (seven male and four female) patients with refractory epilepsy with SBS on EEG, aged between 4.7 years and 11.3 years, were included in this study. After a 3-month baseline period, the patients were given LEV at an initial dose of 10 mg/kg/day for the first week, followed at increments of 5 mg/kg/day every week, up to 20 mg/kg/day. The LEV dose was then adjusted up to a maximum of 60 mg/kg/day, according to the clinician's judgment. EEG recordings and clinical evaluations were performed every 3 months, focusing on SBS. The occurrence of SBS was then scored, and the relationship between the score and the response to LEV treatment was evaluated. In comparison with the baseline SBS frequency, the EEG response to LEV treatment was classified, and responders were identified as having a ≥50% reduction in SBS frequency. In addition, in comparison with the baseline seizure frequency, response to LEV treatment was classified. Responders were identified as patients with complete cessation (100% seizure control) and a response of ≥50% reduction in seizures. Furthermore, neuropsychological impairments such as hyperactivity, impulsiveness, and inattention were evaluated before and after LEV treatment.ResultsEight patients (72.7%) were considered responders. In addition, all eight patients were also considered responders for clinical seizures. Furthermore, 7 of 8 (87.5%) patients with response showed decreased hyperactivity and impulsivity after LEV administration.ConclusionsThe present data clearly indicate the usefulness of LEV in reducing both SBS on EEG and seizure frequency. LEV represents an important addition to the treatments available for refractory childhood epilepsies with SBS on EEG.     

Pneumocystis jirovecii pneumonia associated with etanercept treatment in patients with rheumatoid arthritis: a retrospective review of 15 cases and analysis of risk factors

Objectives

The association of anti-tumor necrosis factor therapy with opportunistic infections in rheumatoid arthritis (RA) patients has been reported. The goal of this study was to clarify the clinical characteristics and the risk factors of RA patients who developed Pneumocystis jirovecii pneumonia (PCP) during etanercept therapy.

Methods

We conducted a multicenter, case–control study in which 15 RA patients who developed PCP were compared with 74 RA patients who did not develop PCP during etanercept therapy.

Results

PCP developed within 26?weeks following the first injection of etanercept in 86.7% of the patients. All PCP patients presented with a rapid and severe clinical course and the overall mortality was 6.7%. Independent risk factors were identified using multivariate analysis and included age ≥65?years [hazard ratio (HR) 3.35, p?=?0.037], coexisting lung disease (HR 4.48, p?=?0.009), and concomitant methotrexate treatment (HR 4.68, p?=?0.005). In patients having a larger number of risk factors, the cumulative probability of developing PCP was significantly higher (p?<?0.001 for patients with two or more risk factors vs. those with no risk factor, and p?=?0.001 for patients with one risk factor vs. those with no risk factor).

Conclusion

Physicians must consider the possibility of PCP developing during etanercept therapy in RA patients, particularly if one or more risk factors are present.     

Left Brachial Approach for Transcatheter Arterial Embolization with Hepatocellular Carcinoma Therapy in Patients

We evaluated the efficacy of thelipiodol-transcatheter arterial embolization (L-TAE)technique for hepatocellular carcinoma (HCC) performedusing a left brachial approach. A total of 64 procedureswere performed using the brachial route in 53patients with HCC between 1989 and 1996 using a 4-Frenchcatheter and these patients were retrospectivelystudied. The technical success rate was 95.3%. Theoverall complication rate was 31.3%: fever of over38.0°C lasting longer than three days (18.8%),transient neurologic complications (4.7%), andpancreatitis (1.6%). Complications such as lumbago, backpain, and dissection of the celiac artery or itsbranches, which frequently complicated femoralapproaches, were avoided. These data indicate that L-TAEusing the left brachial approach may be a safe andeffective alternative to the transfemoral approach inpatients with HCC.     

Biocompatibility of Heparin-Coated Circuits in Pediatric Cardiopulmonary Bypass

Abstract: In this study, we evaluated the biocompatibility of heparin-coated circuits in pediatric cardiopulmonary bypass (CPB). Eight patients were divided into 2 groups: the control group (Group C) and heparin-coated group (Group H). In Group H, CPB circuits, including the arterial pump, oxygenator, and cannulas were heparin-coated. Before, during, and after CPB, blood samples were obtained to assess the platelet counts (Plat), α2-plasmin plas-minogen inhibitor complex (PIC), thrombin-antithrombin III complex (TAT), C3 activation products (C3a), inter-leukin (IL)-6, IL-8, and polymorphonuclear neutrophil leukocyte (PMN) elastase. There was no significant difference in Plat, PIC, or TAT between groups. Group H showed significantly low levels of C3a (during and after CPB), PMN elastase (during CPB), and IL-6 (after CPB). These data demonstrated that in pediatric CPB, heparin-coated CPB circuits reduced the activation of complements and the production of PMN elastase and IL-6, suggesting the superior biocompatibility of the heparin-coated circuits.     

Ultrastructural changes in follicular cells induced by granulosa and theca cell interactions

Bovine granulosa and theca cells were cultured on the opposite sides of a collagen membrane, and the morphological and structural effects of the interaction between theca and granulosa cells were studied. The apical surface of both granulosa and theca cells in the cocultured group appeared convex, while control cells were thin and flat. Numerous filopodia spread over the cellular surface connecting the cells. Constituents of rough endoplasmic reticulum in the cocultured cells were extended and swollen when compared with those observed in the cells cultured alone. Cocultured granulosa cells formed multilayered sheets, while granulosa cells cultured alone formed monolayered sheets. Theca cells in the cocultured group were more densely packed than cells cultured alone. These results indicate that the levels of cellular activity and intercellular communication among each type of cell are increased by the granulosa and theca cell interactions.