Keiichiro Kondo

Angiotensin II receptor antagonist, L-158,809, prevents intimal hyperplasia in dog grafted veins.

We investigated the levels of the angiotensin II-forming enzymes, chymase and angiotensin converting enzyme (ACE), in dog grafted veins, and studied the effect of an angiotensin II type 1 receptor antagonist, L-158,809, on vascular proliferation in the grafted veins. The right external jugular vein was grafted to the ipsilaterial carotid artery. In the group treated with L-158,809, the drug (10 mg/kg per day, p.o.) were administered orally from 7 days before the operation to 28 days after it, while the others were administrated placebo. In the placebo-treated group, the chymase activity in the grafted veins was increased about 10-fold and the ACE activity was doubled. The areas of intima and media were significantly increased in the grafted veins in the placebo-treated group. L-158,809 significantly reduced the intimal area of the grafted veins. An angiotensin II receptor antagonist, L-158,809, prevented the vascular proliferation in the grafted veins, and the development of the proliferation may depend on activation of local angiotensin II formation.

Coronary artery bypass graft surgery in dialysis patient

To determine the operative outcome of coronary artery bypass graft surgery (CABG) for severe coronary artery disease in long-term hemodialysis patients, we analyzed a group of 16 patients who underwent CABG over a ten-year period in our institution. Hospital mortality was 12.5% (2 of 16 patients). These two patients died of ischemic colitis and perioperative myocardial infarction, respectively. There were five late deaths: one patient died from myocardial infarction, one from uremia, one from gastro-intestinal bleeding, one from gastric cancer and one from unknown cause. There were four significant postoperative complications (morbidity 25%), consisted of one pulmonary tuberculosis, one sternal dehiscence secondary to mediastinitis, one mediastinal hematoma secondary to late bleeding from the LITA dissection area and one A-V shunt trouble. Graft patency rate within the first two months was 93% (30 to 42 in 13 patients). Hospital survivors experienced complete relief from angina. Actuarial survival was 68.8% at 3 years, 57.3% at 5 years and 28.6% at 7 years. This rate is not significantly different from the survival of all dialysis patients, but seems to be better than that of dialysis patients with not operated coronary artery disease. We concluded that CABG in dialysis patients can be accomplished with acceptable morbidity and mortality and effective relief of symptoms.

Connexin 43 expression is associated with vascular activation in human radial artery

The gap junction protein, connexin 43 (Cx43) might be involved in the development of atherosclerosis. However, little is known about Cx43 expression in human arteries. We histologically analyzed the distal portions of radial (RA) and internal thoracic arteries (ITAs) obtained from 29 patients undergoing coronary artery bypass graft surgery. The medial smooth muscle cells of RA expressed Cx43, the intensity of which correlated with nuclear factor kappa B (NFκB) activation. In contrast, the expression of Cx43 in ITA did not correlate with NFκB activation. Cx43 appears to be involved in the pathogenesis of atherosclerosis especially in muscular arteries.

INDICATIONS AND PROBLEMS OF CORONARY ARTERY BYPASS GRAFTING WITHOUT CARDIOPULMONARY BYPASS

As an alternative method of myocardial protection and to obviate the inherent risks of cardiopulmonary bypass (CPB), we have been performing coronary artery bypass grafting (CABG) without CPB in carefully selected patients. Since the first such operation was successfully performed in Junuary 1995 on a patient with angina pectoris and lung cancer, four other patients have subsequently undergone this technique. This series of 5 patients, being 1 man and 4 women ranging in age from 68 to 80 years, is presented in this report. The reasons for the selection of this procedure were concomitant diseases including lung cancer, a calcified aorta, and myocardial infarction. The mean time of ischemia for each anastomosis was 15.3 ± 5.3min, and the maximum cardiac muscle creatine phosphokinase (CPK-MB) was less than 14 unit/l postoperatively. None of the patients required ventilatory support for longer than 24h postoperatively, and oral intake was started within 24h after extubation in all patients. Postoperative angiography confirmed graft patency and none of the patients developed any ischemic symptoms. All the patients were discharged between 1 and 2 months postoperatively. Thus, the off-pump technique is useful when concomitant diseases are present and will become an alternative method of treatment for coronary artery disease in selected patients.

Removal of the endocardial pacemaker leads —Experience with 16 leads in 10 patients—

Recent advances in pacemaker leads have contributed to the improvement of their stability at the anchored sites. However, we sometimes have difficulty in removing them. We have experienced the removal of 16 leads in 10 patients (male: 7, female: 3) in the last 5 years. The age of patients ranged from 48 to 87 years, and the average was 60. The reasons for the removal were as follows; pocket infection in 6 cases, sepsis in 1 case, ischemic skin erosion in 1 case, retained fractured ventricular lead in 1 case, fracture of Accufix atrial lead in 1 case. The methods of removal consisted of using the removal kit, the snare or the basket snare transvenously, direct surgical approach or a combination of them. We used the removal kit alone in 12 electrodes (6 atrial, 6 ventricular), and removal of 5 atrial and 3 ventricular leads were successfully by this method only. The removal of 4 leads by kits alone failed, so that 2 ventricular leads were removed transvenously, one atrial and one ventricular lead were removed surgically, and 1 ventricular lead was left untreated. Finally, we were able to remove 15 of 16 leads (93.3%) successfully. This experience indicates that these interventions should be performed as less invasively as possible, yet we should give an explanation to the patients as to the options we may employ when we have failed in the intended procedure.

Selection of Operative Procedures for Reflux Esophagitis.

逆流性食道炎の術式の適応に関して自験例30例を非狭窄例と狭窄例に分けて検討した.非狭窄例22例にHill変法+3/4周fundoplication (H-F法) を施行し, 術後のAFP (anatomy, function, pathol.ogy) 分類ではA gradingで12例中12例 (100%), F gradingで12例中11例 (92%), P gradingで12例中10例 (83%) に改善が認められた.術後遠隔期 (2～11年) のアンケート調査では「胸やけ」や「逆流」症状が「毎日ある」症例はみられなかった.手術終了時のlower esophageal sphincter pressure (LESP) は18.0～40.0mmHgに上昇した.狭窄例8例中4例にCollis-Nissen法 (C-N法), 3例にBelsey Mark IV法 (B法), 1例に食道切除術を行い, C-N法2例に再発が認められた.B法3例では術後LESPが11mmHg, 18.7mmHg, 31.3mmHgに上昇し術後経過良好であった.以上の結果より非狭窄例にはHsF法を, 狭窄例にはB法を第1選択と考えているが, 狭窄例では, 術前拡張療法および食道内圧検査施行後に最適の術式選択を行うべきである.

Tumor Infiltrating Lymphocytes (TIL) and Neoadjuvant Chemotherapy in Esophageal Cancer

Cisplatin (CDDP) has an antineoplastic action mechanism which directly inhibits DNA synthesis. However, another action mechanism of cytotoxic action, i.e., enhancement of spontaneous monocyte-mediated cytotoxicity (SMMC) has been reported [1].

Simultaneous coronary and abdominal aortic surgery —A report of two cases—

Myocardial infarction is a major cause of operative mortality following abdominal aortic surgery. For this reason, routine coronary angiography and, if indicated, coronary revascularization prior to aneurysm repair is recommended. Nevertheless, some controversy still exists concerning the risks of aneurysm rupture and myocardial ischemic events when repair or coronary surgery is staged. This report describes two successful cases of simultaneous surgery for an expanding aneurysm and severe coronary artery disease, emphasizing the usefulness of gastroepiploic artery grafting in such cases.