Katsuhiko Ihara

Tetralogy of Fallot Associated with Aortic Insufficiency

Five patients with tetralogy of Fallot associated with aortic insufficiency were studied. They ranged from 6 to 34 years old (mean, 14 years), and 2 patients had a history of subacute bacterial endocarditis. Four patients had a bulboventricular type of ventricular septal defect. Prolapse of the right coronary cusp was the main cause of aortic insufficiency. Deformed valve secondary to subacute bacterial endocarditis and severe dilatation of the aortic annulus were the other causes. In addition to repair of the tetralogy defect, aortic valvuloplasty was performed in 2 patients. In the remaining 3 patients, the ventricular septal defect was closed with a relatively small-sized patch and no aortotomy was made. Four patients survived the operation, and no residual aortic insufficiency was observed in 3 of them. The etiology and the method of operation are discussed.

Relationship between coagulation cascade, cytokine, adhesion molecule and aortic aneurysm.

OBJECTIVES Patients with aortic aneurysm (AA) were in the chronic inflammatory condition and are often combined with disseminated intervascular coagulation. Recent studies demonstrated that atherosclerosis was inflammatory disease. AA and severe atherosclerosis with ulcer formation contain macrophages and T lymphocytes and accelerate the production of interleukin (IL)-2, which activates lymphocytes and lead to further adhesion of leukocytes. This study was designed to clarify the coagulation condition, cytokine, adhesion molecule, and collagen turnover in patients with AA and finally their relationship with the aneurysmal size. METHODS Thrombin-antithrombin III complex (TAT), plasma D-dimer, serum type III procollagen peptide (PIIIP), serum soluble IL-2 receptor (sIL-2R), Free tissue factor pathway inhibitor (TFPI), and soluble intercellular adhesion molecule (ICAM-1) were measured preoperatively around the same period when computed tomography (CT) was taken in 17 patients with AA (mean age: 72.2 years). Age-matched (mean age:70 years) volunteers were served as control. Maximum aneurysmal size was measured by CT and aneurysmal volume was also calculated from CT. RESULTS AA patients showed significantly higher level in preoperative TAT and D-dimer compared to control (TAT: control 2.5+/-1.2 ng/ml, pre 7.2+/-4.5,ng/ml; P=0.0001; D-dimer: control 107+/-46 U/ml, pre 420+/-256 U/ml; P=0.0001). Cytokine also showed higher level preoperatively (sIL-2R: control 398+/-132 U/ml, pre 735+/-260 U/ml; P=0.0001). TFPI showed higher value preoperatively (control 22.9+/-4.9 ng/ml, pre 30.4+/-6.9 ng/ml; P=0.003). PIIIP (collagen turnover) showed no difference between the groups (P=0.0057) and neither did ICAM-1(P=0.0087). TAT (r=0.799, P=0.0001), D-dimer (r=0.56, P=0.0193), sIL-2R (r=0.709, P=0.0021), PIIIP (r=0.561, P=0.00239), and sICAM-1 (r=0.505, P=0.046) level showed positive correlation with aortic aneurysmal size and also TAT D-dimer, and sIL-2R levels were positively correlated with aneurysmal volume (r=0.714 P=0.0013, r=0.556 P=0.00204, r=0.693 P=0.0029, respectively). CONCLUSIONS AA patients were in the hypercoagulation and inflammatory condition. Aneurysmal size was well correlated with TAT, D-dimer, sIL-2R, PIIIP, and sICAM-1, suggesting that these markers could be good diagnostic and monitoring tool for the disease progression.

Relationship between Hemostatic Markers and Circulating Biochemical Markers of Collagen Metabolism in Patients with Aortic Aneurysm

Our objective was to determine the relationship between plasma levels of hemostatic molecular markers – D-dimer and thrombin-antithrombin III complex (TAT) – and circulating biochemical markers of collagen metabolism – aminoterminal propeptide of type III procollagen (PIIIP) and carboxyterminal propeptide of type I procollagen (PICP) – in patients with aortic aneurysm. The subjects were 43 patients with aortic aneurysm (AA; mean age 71 years) and 26 age-matched controls (mean age 75 years). The mean D-dimer, TAT and PIIIP levels were higher in the patients than in the controls (p < 0.0001, 0.0001 and 0.012, respectively), while the mean PICP level was similar to that in the controls. Increased D-dimer had a significant correlation with PIIIP (r = 0.412, p = 0.006) and PICP (r = 0.342, p = 0.0246), while TAT correlated with PIIIP (r = 0.3194, p = 0.0374), but not with PICP. There was also a significant correlation (r = 0.306, p = 0.0463) between PIIIP and PICP. As shown by the significant positive correlations among D-dimer, TAT and PIIIP, accelerated fibrinolysis and thrombogenesis induce an increase of collagen degradation and procollagen synthesis in atherosclerotic lesions. These findings show that D-dimer and TAT, especially the former, may be useful markers to monitor the progression and predict the prognosis of AA.

Reliable and cost-effective system for surgical stent graft insertion

For intraoperative stented graft implantation, we use a half-inch translucent soft polyvinyl tube as a sheath and an obturator from a two-stage venous cannula as a pushing rod. Ten centimeters of any kind of graft can be used for the stent graft itself. The stent we used was a self-expandable Gianturco double Z stent and was sutured inside the graft.

Tooth extractions and sick sinus syndrome

The experience of tooth extraction in four patients with sick sinus syndrome (SSS) is described, and electrocardiographic features and a guideline for dental extractions are discussed. Patients controlled by medical therapy were safely treated under administration of an effective drug prior to treatment, while patients with a cardiac pacemaker were examined and checked on the apparatus before tooth extraction by their own specialist. After freedom from the cardiac problems, dental extractions were done smoothly. Electrocardiographically, in the cases with pharmacological treatments, either normal sinus rhythm revealed after additional administration of isoproterenol, or more severe bradycardia-tachycardia pattern was shown immediately after tooth extraction. In the patients with a cardiac pacemaker, ECG presented patterns controlled by pacemaker but beats rose from their own sinus node in the anesthesia-extraction procedure with various grades.