Combined coronary artery bypass grafting and abdominal aortic aneurysm repair

The purpose of this paper was to assess the results and feasibility of simultaneous coronary artery bypass grafting and abdominal aortic aneurysm repair. Twenty nine patients with a mean age of 65 years underwent simultaneous coronary artery bypass grafting and abdominal aortic aneurysm repair between June 1990 and March 2002. All patients had significant coronary artery disease and were considered as indicated for coronary artery bypass grafting. This was performed first in 28 patients and simultaneously with abdominal aortic aneurysm repair in one, with a mean number of grafts of 2.5, a mean aortic cross-clamp time of 40 minutes, and a mean bypass time of 115 minutes. Eight straight and 21 bifurcated grafts were employed. The total operating time averaged 400 minutes. The median postoperative hospital stay was 18 days. One patient died of stroke and mediastinitis, for a mortality rate of 3.5%. This experience suggests that combined coronary artery bypass grafting and abdominal aortic aneurysm repair is both safe and effective.     

Intracranial hemorrhage in neuro-Behçet's syndrome

OBJECTIVE: Most cerebrovascular disturbances in Beh?et's syndrome are occlusive in nature, while hemorrhage is rare. In this paper, we report three cases of neuro-Beh?et's syndrome presenting with intracerebral hemorrhaging, and discuss the possible causes as they relate to cyclosporine treatment. PATIENTS: Three cases of neuro-Beh?et's syndrome presented with intracranial hemorrhage. One patient had been taking cyclosporine, and the other two patients had never taking cyclosporine. RESULTS: Together with previous reports, these cases suggest that there are two types of intracranial hemorrhage in neuro-Beh?et's syndrome. One type occurs in the center of a lesion and during the acute phase of the disease, while the other occurs in the peripheral lesion and during the subacute phase. CONCLUSIONS: It appears that the intracranial hemorrhages in neuro-Beh?et's syndrome can be divided into two groups. It is possible that the vascular pathologies caused by Beh?et's syndrome and by cyclosporine conspire to induce CNS hemorrhaging in some cases.     

Current antibiotic prophylaxis in pancreatoduodenectomy in Japan

Background/Purpose

The aim of this study was to investigate the current use of antibiotic prophylaxis (AP) in association with pancreatoduodenectomy (PD) in Japan, and to determine its surgical implications.

Methods

We surveyed 2331 patients who underwent PD for treatment of disease in the periampullary region. Data, obtained during the period January 2002 through December 2003, from 111 major surgical services associated with the Japanese Society for Pancreatic Surgery, were analyzed with regard to patient characteristics, preoperative complications, AP, and postoperative morbidities.

Results

Eighty-five (78.7%) of the 108 eligible institutions chose a first- or second-generation cephalosporin for AP, given for a mean duration of 4.3 days. At all but 1 institution, the first dose was administered prior to surgical incision of the skin. At 42% of the institutions, an additional antibiotic was administered during surgery. The overall rate of wound infection was 6.8% of the 2266 patients for whom data were available. Preoperative jaundice was found in 55.3% of these 2266 patients, and 92.6% of these jaundiced patients were suffering from preoperative infections. In addition, those with preoperative infections were also diagnosed as having biliary infections. The number of patients with preoperative jaundice in combination with preoperative infections was significantly related to the rate of postoperative morbidity (P < 0.0001).

Conclusions

Administration of AP in association with PD in Japan seems appropriate. Icteric patients with biliary infections are at high risk for postoperative morbidities and need careful monitoring after surgery.     

Ala601-Thr type dysplasminogenaemia genetically diagnosed in patients with retinochoroidal vascular disorders

Dysplasminogenaemia has been reported in patients with retinochoroidal vascular disorders. The precise genetic defects of these cases, however, remain unclear because of the limitations of conventional diagnostic techniques. In this study, three patients with these diseases were investigated at the DNA level for the first time to define the molecular bases of these disorders. Polymerase chain reaction–restriction fragment length polymorphism analysis revealed that all three cases carried the same Ala601-Thr mutation. This defect may also play a role in the pathogenesis of circulation disorders in small local vessels because of reduced fibrinolytic activity due to decreased functional plasminogen levels.     

Role of radial strain and displacement imaging to quantify wall motion dyssynchrony in patients with left ventricular mechanical dyssynchrony and chronic right ventricular pressure overload

Left ventricular (LV) deformation with ventricular septal shift is one of the most distinctive echocardiographic observations in patients with chronic right ventricular (RV) pressure overload (PO). However, little is known about the effects of RVPO on LV performance and regional synchrony. Accordingly, our objective was to test the hypothesis that chronic RVPO affects regional wall motion, synchronicity, and global LV function using a novel speckle-tracking approach to quantify and characterize regional LV wall motion dyssynchrony. Displacement and strain imaging echocardiographic studies were performed in 20 patients with RVPO from pulmonary arterial hypertension or pulmonic stenosis (mean age 53 +/- 16 years, New York Heart Association class 2.6 +/- 0.7, and peak RV systolic pressure 73 +/- 28 mm Hg) and 20 age-matched normal subjects (mean age 47 +/- 16 years). Segmental signals from 6 segments around the mid-LV short axis were defined as dyssynchronous if their changes were opposite to that of the global LV signal at each time frame, and overall LV dyssynchrony was calculated as the percentage of dyssynchrony in all 6 segments within the specified time interval from onset of QRS to the end of isovolumic relaxation. RVPO was associated with a large degree of regional dyssynchrony with paradoxical ventricular septal motion observed by displacement imaging (21 +/- 6%, p <0.05 vs control group), which was closely associated with LV eccentricity index (r = 0.79, p <0.05) and LV myocardial performance index with linear regression (r = 0.76, p <0.05). In contrast, strain imaging showed uniform segmental radial thickening in the RVPO group, which was similar to the control group, and suggests that there was no intrinsic LV contractile dyssynchrony. In conclusion, LV wall motion dyssynchrony assessed by displacement imaging, not intrinsic contractile dyssynchrony by strain imaging, coexists with LV chamber deformation with ventricular septal shift and is closely associated with impairment of LV performance.     

Long-term effects of captopril on passive sodium permeability and contractility in vascular smooth muscles of spontaneously hypertensive rats

Long-term effects of captopril on passive sodium permeability and cellular sodium concentration in the aorta of spontaneously hypertensive rats were examined in terms of contractile properties of the muscle. In cold lithium solution, cellular sodium in the aorta isolated from spontaneously hypertensive rats leaked more rapidly than did that isolated from Wistar Kyoto rats (WKY), suggesting an increased sodium permeability in the aorta of spontaneously hypertensive rats. Six weeks of treatment with captopril reduced the increased sodium permeability after hydralazine had failed. Inhibition of the sodium pump by incubating the aorta in potassium-free solution produced a slowly developing contraction which was associated with accumulation of cellular sodium. Both the magnitude of contraction and the accumulation of sodium during exposure to potassium-free solution for 1 hour were significantly less in the aorta isolated from spontaneously hypertensive rats treated with captopril compared with those from control spontaneously hypertensive rats. These data suggest that after prolonged administration, captopril alters the abnormal sodium permeability of vascular smooth muscle in spontaneously hypertensive rats and that the restoration of normal permeability reduces vascular tone.     

Intraortic pulse pressure is correlated with coronary artery stenosis

There is increasing evidence that peripheral pulse pressure measured at the brachial artery is a good predictor of coronary heart disease. However, the relation between pulse pressure and angiographically demonstrated coronary artery stenosis has not been fully elucidated. We designed the present study to investigate the association of the various components of blood pressure, such as systolic pressure, diastolic pressure, and pulse pressure of both peripheral and central arteries with angiographically determined coronary artery stenosis. Levels of aortic systolic pressure, aortic diastolic pressure, aortic pulse pressure, peripheral systolic pressure, peripheral diastolic pressure, and peripheral pulse pressure were determined in 323 patients who underwent diagnostic coronary angiography. Of these 323 patients, 215 patients had significant organic coronary artery stenosis. Aortic pulse pressure was significantly higher in patients with coronary artery stenosis (P = 0.0050). Aortic diastolic pressure was lower in patients with coronary artery stenosis (marginally significant, P = 0.0462). However, no statistically significant difference was observed between other blood pressure components and coronary artery stenosis. Multivariate analyses showed that aortic pulse pressure was associated with coronary artery stenosis independently of aortic diastolic pressure. Moreover, aortic pulse pressure was positively correlated with the number of vessels involved (P = 0.0024). The results of the present study indicate that aortic pulse pressure is significantly and independently correlated with angiographically determined coronary artery stenosis.     

Repeated resection for extrahepatic recurrences after hepatectomy for ruptured hepatocellular carcinoma

In March 1999, a 54-year-old man with chronic hepatitis C was referred to our hospital because of ruptured hepatocellular carcinoma (HCC) located in Couinaud’s segments 4 and 8. He underwent central bisegmentectomy of the liver with partial resection of the diaphragm. After the first surgery, extrahepatic metastases were found on different occasions in the abdominal wall, thoracic cavity, and greater omentum and were all surgically resected. In February 2001, the serum protein induced by vitamin K absence or antagonist-II (PIVKA-II) level increased markedly to 19?000?mAU/l. Magnetic resonance imaging showed a massive right subphrenic tumor with invasion to the right diaphragm and posterior segment of the liver. The patient underwent en bloc resection of the tumor, diaphragm, posterior segment of the liver, and right lower pulmonary lobe. After the surgery, the PIVKA-II level rapidly decreased, and it has remained within the normal range to date. Two years after the last surgery, the patient is doing well without any extrahepatic recurrence, although small intrahepatic recurrences have been completely treated by radiofrequency ablation and transcatheter arterial chemoembolization. Ruptured HCC often exacerbates the risk of peritoneal dissemination and is usually difficult to completely resect. This is an extremely rare case of a patient who successfully underwent five repeated resections for extrahepatic recurrences after hepatectomy for ruptured HCC.