Quantitative improvement in signal-averaged electrocardiography after coronary artery bypass grafting.

Abnormal signal-averaged electrocardiography (SAECG) reflects slow and heterogeneous myocardial conduction, predicting ventricular arrhythmia and sudden cardiac death in patients with ischemic heart disease. The purpose of this study was to investigate the quantitative effect of coronary artery bypass grafting (CABG) on SAECG, which is still controversial, and to identify the factors that are related to it. Pre- and postoperative SAECGs were recorded in 100 patients who underwent CABG. Compared parameters included filtered QRS duration (dQRS), root mean square voltage in the terminal 40 ms of the QRS complex (RMS40), and duration of the terminal low-amplitude signal less than 40 microV (LAS40). All 3 parameters in SAECG improved significantly after CABG (dQRS: 105+/-21 ms-->99+/-18 ms, RMS40: 55+/-45 microV-->65+/-41 microV, LAS40: 29+/-19 ms-->25+/-12 ms). The improvements in SAECG were greater in patients who underwent complete revascularization and in those without prior myocardial infarction. In conclusion, CABG improved SAECG quantitatively, even in patients with normal SAECG. However, this improving effect was variable and closely related to the presence of prior myocardial infarction and the completeness of revascularization.     

Plasma 11-deoxycortisol response to single dose metyrapone in prostatic cancer patients (author's transl)

A radioimmunoassay procedure for plasma 11-deoxycortisol (S) was developed using an antiserum prepared by immunizing rabbits with S-21-hemisuccinate bovine serum albumin and S-3-oxime-bovine serum albumin. Thereafter plasma S, cortisol (F) and adrenocorticotropic hormone (ACTH) responses to metyrapone were investigated in 13 normal adult males and 39 patients with prostatic cancer. The results were as follows: 1) The antiserum against S-3-oxime-bovine serum albumin had less cross reactivity (less than 10%) with other steroids than that against S-21-hemisuccinate bovine serum albumin and obtained a good standard curve. The intra-assay variance and interassay variance of this method using the former antiserum (N = 10) were 12.4% asd 14.9% respectively, and the blank value was 3.7 +/- 1.6 pg. 2) Basal levels of S. F and ACTH in plasma from 13 normal adult males, ranged 21 approximately 80 years, old, were 98.4 +/- 15.7 ng/dl (mean value +/- S.E.), 12.7 +/- 0.78 micrograms/dl and 30.6 +/- 3.02 pg/ml respectively. Those level increased to 7060 +/- 598 ng/dl, 24.3 +/- 1.69 micrograms/dl and 24.3 +/- 1.6 pg/ml at 9 a.m. following oral administration of metyrapone (30 mg/kg b.w.) at midnight. 3) Both basal levels and responses of plasma S and F to metyrapone increased remarkably, while those of ACTH were within the normal range in prostatic cancer patients during the estrogen therapy. It was considered that protein-bound S and F increased following elevation of corticosteroid binding globulin but returned to the normal range about 2 weeks after discontinuation of the therapy. 4) In case treated wih estrogens, plasma, S, F and AC normal range in prostatic cancer patients during the estrogen therapy. It was considered that protein-bound S and F increased following elevation of corticosteroid binding globulin but returned to the normal range about 2 weeks after discontinuation of the therapy. 4) In case treated wih estrogens, plasma, S, F and AC normal range in prostatic cancer patients during the estrogen therapy. It was considered that protein-bound S and F increased following elevation of corticosteroid binding globulin but returned to the normal range about 2 weeks after discontinuation of the therapy. 4) In case treated wih estrogens, plasma, S, F and ACTH responses to metyrapone were unchanged compared to normal adult males 2 approximately 4 weeks after discontinuation of the therapy, and this data suggested that estrogens had no inhibitory effect on the pituitary-adrenal axis. However, in cases treated with progestational agents over a long-term period, plasma S and ACTH responses to metyrapone decreased slightly but returned to the normal range 2 approximately 4 weeks after discontinuation of the therapy. This suggested that the inhibitory effect of these agents on the pituitary-adrenal axis was mild and reversible.     

Surgery for hepatocellular carcinoma with tumor thrombus extending into the right atrium: report of a successful resection without the use of cardiopulmonary bypass

Hepatocellular carcinomas, of which the tumor thrombus extends into the right atrium via the inferior vena cava, may soon cause fatal complications. Only surgery can be an effective treatment. This procedure usually needs the aid of cardiopulmonary bypass. We recently experienced a successful surgery to remove thrombus combined with hepatectomy. Reporting the detailed technique, both associated diagnosis and intraoperative management are discussed herein. We were able to perform hepatectomy of tumor thrombus in the right atrium without the use of cardiopulmonary bypass or veno-venous bypass. The tumor thrombus was removed from the right atrium into the suprahepatic inferior vena cava by reducing the liver on the tail side. And after total hepatic vascular exclusion was achieved, the intracaval tumor thrombus and the right lobe of the liver were removed en bloc. The operation took 545 minutes and the total hepatic vascular exclusion period was 32 minutes. The postoperative course was uneventful. There are some key points for this procedure. Preoperative or intraoperative US is essential in judging whether tumor thrombus can be removed from the right atrium into the inferior vena cava by reducing the liver or not. Test clamping of the inferior vena cava prior to total hepatic vascular exclusion will enable us to judge whether veno-venous bypass during total hepatic vascular exclusion is needed or not. Surgery without the use of cardiopulmonary bypass is safe and can be minimally invasive when it is performed with a reliable diagnosis and technique.     

Lack of an association between T-wave alternans and ST-segment depression during exercise-induced ambulatory ischemia

It is known that T-wave alternans (TWA), which identify patients at risk for arrhythmic events, often occur during acute coronary occlusion in association with ST-segment elevation. To test the hypothesis that TWA is associated with a certain state/severity of myocardial infarction/ischemia, we assessed the association between TWA and ST-segment depression during exercise-induced ambulatory ischemia. Of 351 consecutive patients with coronary artery disease who underwent assessment of microvolt TWA by exercise, 23 patients with effort angina without a history of infarction with ST depression (> or =0.11 mV) during TWA test were selected. These patients were compared with 222 postinfarction patients consisting of 38 patients with, and 184 patients, without the ST depression, and 18 normal individuals. The incidence (9%) of determinate TWA in the patients with angina was significantly (P < .0001) lower than that (52%) in the postinfarction patients. There was no significant difference between the angina patients and the controls (6%). There was also no difference between the patients with (58%) and without the ST depression (51%) in the postinfarction patients. Moreover, no correlation existed between the TWA voltage and the ST-depression magnitude in both angina and postinfarction patients. We concluded that there is no association between TWA and ambulatory ischemia with ST depression.     

Study for determination of the optimal cessation period of therapy with anti-platelet agents prior to invasive endoscopic procedures

Background Anti-platelet agents are widely used for the treatment and prevention of thrombotic diseases. On the other hand, continuation of anti-platelet agents increases the risk of hemorrhagic complications in gastrointestinal endoscopy, and cessation of anti-platelet agents exposes the patient to the risk of thromboembolism. Only a few studies have actually studied the whether a cessation period is required prior to endoscopic procedures and if so, the optional duration of the period. The present study assessed the time course of primary hemostasis after the cessation of anti-platelet agents.Methods Eleven healthy men (age range, 19–29 years) were assigned to each of the following regimens: aspirin (ASA; 100 mg/day), ticlopidine (TP; 300 mg/day), and a combination of ASA (100 mg/day) and TP (300 mg/day) for 7 days. There was a washout period of more than 3 weeks between each regimen. A quantitative bleeding time test (QBT test) and platelet aggregation test were performed before the beginning of administration, on the last day of administration, and at 1, 3, and 5 days after cessation, and also at 7 days after cessation for the combination regimen.Results The average bleeding time (BT) and total bleeding loss volume (Tv) of the 11 subjects after administration of the three regimens were significantly increased compared with those before administration. With the administration of ASA, increases of BT and Tv at 3 days after cessation were not significant. The Tv at 5 days after cessation of TP was not significantly increased. With the combination regimen, the BT and Tv at 7 days after cessation were not significantly increased.Conclusions A 3-day cessation period for ASA, a 5-day cessation period for TP, and a 7-day cessation period for ASA + TP administration seem to be sufficient.     

Combined primary aldosteronism and Cushing's syndrome due to a single adrenocortical adenoma complicated by Hashimoto's thyroiditis

A 43-year-old Japanese woman presented hypertension, hypokalemia and typical Cushingoid signs. Autonomous secretion of both aldosterone and cortisol was shown. Abdominal computed tomography demonstrated a single tumor in the right adrenal gland, which established the diagnosis of combined primary aldosteronism and Cushing's syndrome. The resected tumor was a golden yellow-colored adenoma (diameter 4.3 cm) which expressed P450(aldo) and P450(11beta), causing oversecretion of both hormones from this adenoma. After tumor resection, overproduction of both hormones disappeared and she developed adrenal insufficiency, suggesting the strong suppression of normal adrenal function. This case was complicated by Hashimoto's thyroiditis.     

Diagnostic Value of Lipiodol Injection in Focal Nodular Hyperplasia of the Liver

We encountered a case of small focal nodular hyperplasia (FNH) of the liver. It was difficult to distinguish FNH from hepatocellular carcinoma by means of sonography, computed tomography (CT), and angiography. After the injection of Lipiodol, it accumulated densely on FNH, but was washed away after a short time, as observed on the follow-up CT. This progress was different from that in hepatocellular carcinoma.