Kenji Takazawa

AUTOLOGOUS BLOOD TRANSFUSION WITH RECOMBINANT HUMAN ERYTHROPOIETIN IN HEART OPERATIONS

The effects of recombinant human erythropoietin (rHuEPO) on improving the anemia associated with autologous blood collection before open heart operations and on improving the postoperative anemia were studied. The study was carried out on 18 patients undergoing coronary artery bypass operations; 400 mL of autologous whole blood was taken from each patient 2 weeks before operation and was subsequently used in the operation, and rHuEPO (100 U.kg-1.day-1) was given intravenously for 2 weeks before operation and for 1 week after operation. The group in which iron preparations were also administered intravenously was designated as group I (10 patients), and the group in which rHuEPO was given alone was designated as group II (8 patients). In group III, as a control group, 11 past patients were used in whom 400 mL of autologous whole blood was collected 2 weeks before operation but neither rHuEPO nor iron preparations were given. After autologous blood collections, the hemoglobin levels improved in group I, group II, and group III, in that order, and with significant differences among them. It was shown that rHuEPO was effective in ameliorating the anemia associated with preoperative autologous blood collection, and the effect was further enhanced with intravenous supplementing iron preparations. After operation, the anemia markedly improved while rHuEPO was administered, but the hemoglobin levels decreased rapidly when the administration was terminated. Further studies are needed regarding the use of rHuEPO after operation.

Coronary artery bypass grafting in patients on chronic hemodialysis: surgical outcome in diabetic nephropathy versus nondiabetic nephropathy patients

BACKGROUND The presence of diabetes mellitus adversely affects the late survival of patients undergoing coronary artery bypass grafting (CABG). The purpose of this study is to clarify the role of diabetic nephropathy on outcomes of a group of patients on chronic hemodialysis undergoing CABG. METHODS Between April 1984 and July 1999, 45 patients on chronic hemodialysis underwent CABG. Forty-three had conventional CABG and 2 had off-pump CABG. There were 37 males and 8 females, and the mean age was 57 years (43 to 76 years). Twenty-one patients had diabetic nephropathy (group D) and 24 had nondiabetic nephropathy (group ND). Early and late results were determined in both groups. RESULTS Early outcome was not significantly different between the groups. There was no hospital mortality, stroke, or requirement for prolonged mechanical ventilation (>24 hours) in either group. No patients in group D, and only 1 (4.2%) in group ND had low cardiac output syndrome. The difference in the incidence of arrhythmias (23.8% in group D and 25% in group ND), wound infections (9.5% in group D and 8.3% in group ND), and delayed tamponade (5% in group D and 12.5% in group ND) was not statistically significant. However, late results differed significantly between the two groups. Actuarial survival (Kaplan-Meier) at 5 and 9 years was 22.9% and 11.5% in group D and 89.1% and 45.7% in group ND (p = 0.01), respectively. Similarly, the cardiac event-free rate at the same intervals was 50.4% and 0% for group D and 100% and 65.8% for group ND (p = 0.001), respectively. CONCLUSIONS Using present technology, CABG can be done in patients on chronic hemodialysis with acceptable early mortality and morbidity. Late results in patients with diabetic nephropathy on hemodialysis are not as favorable as their nondiabetic cohort.

Metal allergy to stainless steel wire after coronary artery bypass grafting.

Abstract To our knowledge, this is the first reported case of a manganese metal allergy to stainless steel wire. A 51-year-old man suffered from a refractory pruritic erythematous wheal after the insertion of a stainless steel wire. The patch test showed strong reactions to manganese, one of the constituents of stainless steel wire. After the removal of all stainless steel wires, the symptoms were much improved, except for mild pruritus on his face.

Induction of persistent allograft tolerance in the rat by combined treatment with anti-leukocyte function-associated antigen-1 and anti-intercellular adhesion molecule-1 monoclonal antibodies, donor-specific transfusion, and FK506

We previously reported that a short course of treatment with anti-LFA-1 and anti-ICAM-1 monoclonal antibodies (mAbs) led to a persistent acceptance of mouse cardiac allografts, which resulted from the induction of allospecific tolerance. In the present study, we tested the effect of anti-LFA-1 and anti-ICAM-1 mAbs on rat allograft rejection and analyzed the mechanisms underlying allograft tolerance. In sharp contrast to the mouse case, a short course of treatment with anti-LFA-1 and anti-ICAM-1 mAbs led to a persistent acceptance in only half of the treated rats when MHC was compatible but mismatched for minor antigens, and was virtually ineffective when MHC was fully incompatible. However, treatment with these mAbs combined with donor-specific transfusion and FK506 consistently led to a persistent acceptance, even when the MHC was fully incompatible. Donor-specific tolerance was induced by this treatment, as estimated by skin challenging. In the tolerant rats, proliferative response and CTL generation against donor-type alloantigen were severely impaired but partially restored by exogenous interleukin-2. Limiting dilution analysis demonstrated that the precursor frequency of CTL was decreased in the tolerant rats, as compared with the naive rats. These results suggest that donor-reactive T cells were partially deleted and rendered anergic in the periphery.

Effects of safflower seed extract on arterial stiffness

Safflower seed extract (SSE) contains characteristic polyphenols and serotonin derivatives (N-( p-coumaroyl) serotonin and N-feruloylserotonin), which are reported to inhibit oxidation of low-density lipoprotein (LDL), formation of atherosclerotic plaques, and improve arterial stiffness as assessed by pulse wave analysis in animal models. The effects of long-term supplementation with SSE on arterial stiffness in human subjects were evaluated. This doubleblind, placebo-controlled study was conducted in 77 males (35–65 years) and 15 postmenopausal females (55–65 years) with high-normal blood pressure or mild hypertension who were not undergoing treatment. Subjects received SSE (70 mg/day as serotonin derivatives) or placebo for 12 weeks, and pulse wave measurements, ie, second derivative of photoplethysmogram (SDPTG), augmentation index, and brachial-ankle pulse wave velocity (baPWV) were conducted at baseline, and at weeks 4, 8, and 12. Vascular age estimated by SDPTG aging index improved in the SSE-supplemented group when compared with the placebo group at four (P = 0.0368) and 12 weeks (P = 0.0927). The trend of augmentation index reduction (P = 0.072 versus baseline) was observed in the SSE-supplemented group, but reduction of baPWV by SSE supplementation was not observed. The SSE-supplemented group also showed a trend towards a lower malondialdehyde-modified-LDL autoantibody titer at 12 weeks from baseline. These results suggest long-term ingestion of SSE in humans could help to improve arterial stiffness.

Is diabetes mellitus a major risk factor in coronary artery bypass grafting? The influence of internal thoracic artery grafting on late survival in diabetic patients.

OBJECTIVE The presence of diabetes could possibly have an adverse influence on the late results of coronary artery bypass grafting (CABG). A retrospective observational risk-unadjusted estimation study was conducted to clarify the magnitude of this unfavorable influence of diabetes based on our experience at Juntendo University. METHODS Between January 1984 and December 1995, 1,618 primary CABG operations were performed and 99.0% of these patients were followed up for a mean period of 81.2 months with a maximal follow-up of 14 years. Among the 1,610 patients who were successfully followed up, 523 patients (32.5%) were diabetic and this cohort was compared with 1,087 nondiabetic patients regarding the patient profiles, perioperative outcome, and the long-term outcome. RESULTS Diabetic patients included a higher proportion of females, a greater preoperative presence of renal insufficiency, a higher rate of three vessel disease, and reception of a greater number of grafts (mean: 2.5 versus 2.4) and an internal thoracic artery graft (68% versus 58%). Hospital mortality was not significantly different (2.1% vs 1.0%: ns). An actuarial analysis revealed a significantly unfavorable long-term survival in the diabetic group (59.6%) at 14 years, compared with the nondiabetic group (73.4%), however diabetic patients with an internal thoracic artery graft had a favorable long-term survival (82.0%) at 13 years, and this finding was almost identical to that of nondiabetic patients with an internal thoracic artery graft (88.5%). CONCLUSION We conclude that the presence of diabetes appears to be a major risk factor in patients undergoing CABG. However, diabetic patients with an internal thoracic artery graft had a survival almost identical to that of nondiabetic patients with an internal thoracic artery graft.

Cardiac myxoma with Gamna-Gandy bodies: case report with MR imaging

We describe a patient with a left atrial tumor that showed very unusual magnetic resonance (MR) imaging features. Postsurgical histologic examination showed characteristics of myxoma, and Gamna-Gandy bodies were found in the tumor. We believe that the unusual MR appearance was caused by the hemosiderin in the Gamna-Gandy bodies.

Off-pump coronary artery bypass grafting in a patient with liver cirrhosis

We report a case of unstable angina pectoris and alcohol-related Child-Pugh class B cirrhosis. The patient was a 60-year-old man who was admitted to hospital with chest pain. He had previously been diagnosed to have Child B cirrhosis due to alcoholic liver dysfunction at 58 years of age. He also had experienced ruptured esophageal varices, moderate ascites, and hyperammonemia. We performed percutaneous catheter intervention; however, he developed re-stenosis in the right coronary artery, and progression in the disease in other coronary arteries. We then performed coronary artery bypass grafting on the beating heart without cardiopulmonary bypass. He was discharged on the 13th postoperative day without any complications. This case demonstrated that off-pump coronary artery bypass grafting was safe for such a patient.

Laparoscopic cholecystectomy after coronary artery bypass grafting using the right gastroepiploic artery: Report of a case

Abstract.A laparoscopic cholecystectomy (LC) was successfully performed on a 61-year-old man who had undergone coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA). He complained of right hypochondralgia 20 days after CABG. Gallstones were diagnosed and a cholecystectomy was performed 9 months after CABG. Under general anesthesia, the operation was performed using a pneumoperitonium. When a laparoscope was inserted, the RGEA pedicle could be clearly recognized. The pedicle obstructed the operating field and made the working space narrower than usual. No ST changes on the electrocardiogram were seen during LC, especially during the initiation of pneumoperitonium, the insertion of the ports, or when retracting the gallbladder. The postoperative course was uneventful. To avoid complications, care should be taken not to stretch the RGEA pedicle during LC, and careful monitoring of the electrocardiogram is also necessary. It is difficult to view the operating field and the RGEA pedicle together. It is therefore better to insert another laparoscope for concomitant monitoring of the RGEA pedicle.

CAM--a novel immunosuppressive agent.

This is an initial study of the immunosuppressive efficacy of CAM, a derivative of mycophenolic acid, in a rat heart allograft model when the major histocompatibility complex was fully incompatible, and its effect in improving heart allograft survival compared with mycophenolate mofetil (MMF, RS-61443). CAM or MMF was administered orally from day 1 following the allografting for 40 days. The median survival times (MST) were 6 days in rats with no immunosuppressive drug (control group; n = 6), 83 days with CAM 10 mg/kg (n = 6), and > 100 days with both 20 mg/kg (n = 7), and 30 mg/kg (n = 10). With MMF, in contrast, MST was 9, 17, 35, days with 10, 20, 30 mg/kg/day, respectively. All grafts in the CAM 30 mg/kg-treated group survived for more than 100 days after grafting, and, furthermore, CAM was also more effective than MMF in prolongation of the heart graft survival in rats at each dose. Rats with long-surviving cardiac allografts (30 mg/kg; CAM) accepted skin grafts from the donor-strain but rejected them from the third-party strain, suggesting that donor-specific tolerance was induced by CAM. In the tolerant rats, proliferative response against donor-type alloantigen was not impaired as compared with naive WKAH rats. In contrast, CML assay showed that T cells obtained from the rats bearing permanently accepted F344 heart grafts had less cytotoxic activity to the donor-type target, and the frequency of CTL precursor against donor-type alloantigen was also reduced.