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A 42-year-old woman presented with a 6-month history of palpitations and progressive dyspnea on exertion. She had undergone aortic and mitral valve repair using glutaraldehyde-treated autologous pericardium for active infective endocarditis 5 years prior. Transthoracic echocardiography showed mitral valve stenosis with limited movement of the anterior leaflet. At redo surgery, severe calcification of the glutaraldehyde-treated pericardial patch on the anterior mitral leaflet was observed. Double valve replacement was performed with pulmonary vein isolation. Pathologic examination showed calcification of the glutaraldehyde-treated autologous pericardium. The patient was discharged on postoperative day 11 with oral anticoagulant therapy.

ObjectiveLeft atrial geometry and mechanical functions exert a profound effect on left ventricular filling and overall cardiovascular performance. We sought to investigate the perioperative factors that influence left atrial geometry and mechanical functions after the Maze procedure in patients with refractory atrial fibrillation and left atrial enlargement.MethodsSeventy-four patients with atrial fibrillation and left atrial enlargement (diameter ≥ 60 mm) underwent the Maze procedure in association with mitral valve surgery. The maximum left atrial volume and left atrial mechanical functions (booster pump, reservoir, and conduit function [%]) were calculated from the left atrial volume-cardiac cycle curves obtained by magnetic resonance imaging. A stepwise multiple regression analysis was performed to determine the independent variables that influenced the postoperative left atrial geometry and function.ResultsThe multivariate analysis showed that left atrial reduction surgery concomitant with the Maze procedure and the postoperative maintenance of sinus rhythm were predominant independent variables for postoperative left atrial geometry and mechanical functions. Among the 58 patients who recovered sinus rhythm, the postoperative left atrial geometry and function were compared between patients with (VR group) and without (control group) left atrial volume reduction. At a mean follow-up period of 13.8 months, sinus rhythm recovery rate was better (85% vs 68%, P < .05) in the VR group and maximum left atrial volume was less (116 ± 25 mL vs 287 ± 73 mL, P < .001) than in the control group. The maximum left atrial volume reduced with time only in the VR group (reverse remodeling). Postoperative booster pump and reservoir function in the VR group were better than in the control group (25% ± 6% vs 11% ± 4% and 34% ± 7% vs 16% ± 4%, respectively, P < .001), whereas the conduit function in the VR group was lower than in the control group, indicating that the improvement of the booster pump and reservoir function compensated for the conduit function to left ventricular filling.ConclusionLeft atrial reduction concomitant with the Maze procedure helped restore both contraction (booster pump) and compliance (reservoir) of the left atrium and facilitated left atrial reverse remolding. Left atrial volume reduction and postoperative maintenance of sinus rhythm may be desirable in patients with refractory AF and left atrial enlargement.

ObjectiveLarge left atrial diameter is reported to be a predictor for recurrent atrial fibrillation after the Cox maze procedure, and left atrial diameter by itself influences the chance of sinus rhythm recovery, as well as maintenance of sinus rhythm. However, additional cut-and-sew procedures to decrease left atrial diameter extend operative time and can cause bleeding. Thus we developed a no-bleeding, faster, and therefore less invasive left atrial volume reduction technique to enhance the Cox maze procedure.MethodsThe modified Cox maze III procedure with cryoablation or the left atrial maze procedure in association with mitral valve surgery was performed in 80 patients with atrial fibrillation and enlarged left atria (≥60 mm). Among them, 44 patients had the concomitant volume reduction technique (VR group); continuous horizontal mattress sutures for left atrial plication were placed on the left atrial wall along the pulmonary vein isolation line. Cryoablation was applied to the suture line so that the plicated left atrium is anatomically and electrically isolated. Another 36 patients did not have the volume reduction technique (control group).ResultsThe VR group had preoperative left atrial diameters similar to those of the control group (67.1 ± 7.8 vs 64.5 ± 6.7 mm) and a longer preoperative duration of atrial fibrillation (14.1 ± 5.4 vs 9.5 ± 5.1 years, P < .05) but had smaller postoperative left atrial diameters (47.6 ± 6.3 vs 62.1 ± 7.9 mm, P < .01). There were no differences in mean crossclamp/bypass time and chest tube drainage for 12 hours between the groups. Twelve months after surgical intervention, the sinus rhythm recovery rate of the VR group was better than that of the control group (90% vs 69%, P < .05).ConclusionsEven in patients with long-standing atrial fibrillation and an enlarged left atrium, maze procedures concomitant with the novel left atrial volume reduction technique improved the sinus rhythm recovery rate without increasing complications. Although further study with a larger number of patients and a longer follow-up period is needed, this safe and thus far potent technique that catheter-based ablation cannot copy might extend indication of the Cox maze procedure for patients with tough atrial fibrillation.

Background. Observation during open heart surgery in patients with chronic atrial fibrillation (AF) showed that the activation sequence of the left atrium was regular and that of the right atrium chaotic in most patients. We speculate that the left atrium plays a role as an important electrical driving chamber for AF and by mapping preoperatively, optimal sites for the cryoablation can be determined to minimize the extensiveness of the cryolesions. Methods. Forty patients who underwent cardiac surgery and cryoablation guided by epicardial mapping data to eliminate AF originating from the left atrium were included in this study. Results. Sustained reentrant movement or repetitive firing from foci located in the right atrium was never observed. Foci or reentry circuits located in the left atrium were clearly identified in 11 cases. Nine of the 11 cases resumed sinus rhythm by placing cryolesions at these sites. Two cases needed a pacemaker implantation. The exact site had not been identified in the 29 remaining cases. In these 29 cases a left atrial posterior longitudinal linear cryoablation was placed. Sinus rhythm resumed in 22 cases. Six cases still remained in AF and a pacemaker was implanted in 1 case. Ultimately, in this series of operations sinus rhythm was resumed in 31 of 40 cases; AF remained in 6 of them and pacemaker implantation was required in 3 cases. Conclusions. Mapping was useful to distinguish the two etiologies of the AF to facilitate optimal placement of the cryolesions. Sustained reentrant movement or repetitive firing from foci located in the right atrium was never observed and the left atrium played an important role as the electrical driving chamber for AF.

Background . Only a few studies have been done on sequential grafting using the right gastroepiploic artery (GEA). Methods . Forty patients (35 males, ages 36 to 74 years) who underwent sequential grafting of the GEA were reviewed. Angiography of the GEA was performed preoperatively in all patients. GEAs with a luminal diameter greater than 2 mm at the presumptive distal anastomosis on the angiogram were used. The dissected GEA was led into the pericardial cavity through the antegastric route. We used GEAs to graft 89 branches (2.2 per patient) in the inferoposterior region. Results . In 24 patients who had angiographic examinations, all the GEAs were patent, although luminal narrowing was noted in the segment between the two anastomoses in 3 patients. Eight-year actuarial survival was 92.5% and the cardiac-related event-free rate was 95%. Conclusions . Sequential grafting of the GEA can be performed effectively in selected patients. Performing preoperative angiography to assess the size of the GEA for sequential grafting is strongly recommended.

Background . The flow capacity of the right gastroepiploic artery graft has not been clarified. Methods . Angiographic and echocardiographic studies were conducted in 30 patients who had undergone coronary artery bypass grafting using both the internal thoracic and right gastroepiploic arteries. The luminal diameter of the arterial grafts was measured from the postoperative angiograms. The adequacy of the myocardial blood supply from the arterial grafts was evaluated by dobutamine stress echocardiography. Results . With echocardiography, 14 patients exhibited an ischemic response in the gastroepiploic artery grafted region, whereas no patients exhibited an ischemic response in the internal thoracic artery grafted area. The luminal diameter of the gastroepiploic artery and a younger age were correlated with the ischemic response observed in the dobutamine stress echocardiography. A luminal diameter of the gastroepiploic artery of greater than 2.6 mm had the highest sensitivity and specificity for a nonischemic change. Conclusions . To generate the maximal flow reserve, the luminal diameter of the gastroepiploic artery when used as a graft should be sufficiently large enough, nearly 3 mm at the anastomosis.

The treatment of aortic root dilatation with a leaking valve requires a multimodal approach, including root reimplantation or remodeling with or without tailoring of the sinotubular junction and valvular apparatus. However, valve-sparing procedures are time-consuming, technically demanding, and associated with intraoperative bleeding. Here we report a novel reconstruction method for the treatment of annuloaortic ectasia with a leaking valve. In this method the dilated sinuses were excluded, and the annulus was effectively suspended by suturing a bovine pericardial patch inside the dilated aortic root.

Cardiac myxoma sometimes presents constitutive symptoms such as fever and weight loss because of a production of interleukin-6 (IL-6). Castleman’s disease (CD) presents constitutional symptoms with lymphadenopathy, plasma cell infiltration, polyclonal hypergammaglobulinemia, and inflammatory reaction, which has been reported to be caused by an overproduction of IL-6. Here, we report a rare case of IL-6-producing cardiac myxoma resembling multicentric CD with plasma cell infiltration.

Hybrid therapy administered for thoracoabdominal aortic aneurysm involves stent grafts and surgical reconstruction. This therapy entails retrograde visceral artery bypass before stent-graft implantation, establishing an inflow from either the distal abdominal aorta or the iliac arteries. Kinking is of great concern since it may cause acute occlusion, especially in grafts to the celiac axis and superior mesenteric artery because these vessels are directed caudally toward the right. Here, we describe a novel technique to achieve good exposure of the visceral vessels and appropriate graft position.

Un aneurisma toracoabdominal (AATA) tipo II de la clasificacion de Crawford, secundario a diseccion cronica, se trato satisfactoriamente con un procedimiento hibrido que incluyo una reconstruccion visceral quirurgica y la implantacion de dos endoprotesis tipo Inoue. La endoprotesis Inoue con rama proximal sello eficazmente la entrada localizada cerca de la arteria subclavia izquierda y excluyo simultaneamente el AATA, mientras que una segunda endoprotesis tubular colocada distalmente sello la reentrada. La arteria de Adamkiewicz se dejo sin excluir e intacta entre ambas endoprotesis. Las arterias viscerales se reconstruyeron mediante un bypass retrogrado con protesis cuadrifurcada, tunelizacion posterior y anastomosis distal terminoterminal de los cuatro vasos.

Crawford type II thoracoabdominal aortic aneurysm (TAAA) secondary to chronic dissection was successfully treated with hybrid therapy comprising surgical visceral reconstruction and dual Inoue stent graft implantation. The proximal single-branched Inoue stent graft effectively sealed the entry located near the left subclavian artery and simultaneously excluded the TAAA, while the distal tubular Inoue stent graft sealed the reentry; thus, the artery of Adamkiewicz was left unexcluded and intact between the two Inoue stent grafts. The visceral arteries were reconstructed using a quadrifurcated retrograde bypass with posterior aortic tunneling and end-to-end distal anastomosis to all four vessels to achieve a curved and smooth configuration.

Un anevrysme de l'aorte thoraco-abdominale (AATA) de type II de Crawford, secondaire a une dissection chronique, a ete traite avec succes de maniere hybride par une revascularisation viscerale chirurgicale et une double implantation d'endoprothese d'Inoue. Une endoprothese proximale monobranche a couvert la porte d'entree proche de l'artere sous-claviere gauche et a simultanement exclu l'AATA, tandis qu'une endoprothese tubulaire distale d'Inoue a couvert la reentree. Ainsi, l'artere d'Adamkiewicz n'a pas ete couverte et est restee intacte entre les deux endoprotheses d'Inoue. Les arteres viscerales ont ete reconstruites en utilisant un pontage retrograde quadrifurque tunnellise en arriere de l'aorte et anastomose en distalite de maniere termino-terminale aux quatre vaisseaux, afin d'obtenir une configuration harmonieuse.

Possible neuroanatomical loci and the mode of action of thyrotropin-releasing hormone (TRH) or its analog, gamma-butyrolactone-gamma-carbonyl-histidyl-prolinamide citrate (DN-1417), in reducing the pentobarbital-induced sleeping time were investigated by using an intracerebral microinjection technique in rats. Intravenous, intraperitoneal or intracerebroventricular (ICV) injection of TRH or DN-1417 produced a dose-related reduction of the sleeping time induced by pentobarbital. TRH or DN-1417 given into the posterior hypothalamic regions including the dorsal premammillary nucleus, lateral hypothalamic area and posterior nucleus of hypothalamus had a significant pentobarbital sleep shortening action in low doses. Injection of these peptides into the dorsomedial nucleus of thalamus, mesencephalic reticular formation, medial septal nucleus or hippocampus was also effective, in comparatively low doses. However, higher doses were required to elicit the effect when the injections were made into the nucleus accumbens, lateral preoptic area or caudate nucleus. In this respect, the parietal cortex was insensitive to TRH or DN-1417. The pentobarbital sleep shortening action of TRH or DN-1417 injected peripherally or into the hypothalamic regions was markedly antagonized by ICV or intrahypothalamic pretreatment with atropine methyl bromide. On the contrary, ICV injection of atropine methyl bromide had a weak or no antagonizing action on the effect of TRH injected ICV or into the reticular formation, medial septal nucleus or hippocampus. These results suggest that possible neuroanatomical sites mediating the pentobarbital sleep shortening action of TRH or DN-1417 may be posterior hypothalamic regions, dorsomedial nucleus of thalamus, reticular formation, medial septal nucleus or hippocampus. A cholinergic mechanism may also be involved in the effect of TRH on the hypothalamus.

Buchtal and collaborators reported thirty years ago an excitatory action of low (10 −3 M) concentrations of ATP on frog muscle, as well as in increase in the sensitivity of the muscle to ACh. These effects have been re-investigated employing both intra-and extra-cellular recording and the technique of iontophoretic drug application. ATP at a concentration of 10 −4 M decreases the recorded resting potential by about 35%. The depolarizing action of ATP is more pronounced in the tibial end of the frog sartorius muscle than in the nerve free pelvic end. In addition ATP, added to the bath and electro-osmotically applied, increases the depolarizing action of ACh. This potentiating effect is particularly marked in denervated muscles.

Schon fruher haben Gibbs u. Mitarb. (1, 2) von periodischen Veranderungen der elektrischen Aktivitat des Cortex, die zeitlich den Atembewegungen entsprachen, berichtet. Jedoch konnten sic die Beziehungen zwischen elektrischer Aktivitat des Zentralnervensystems and der Atmung nicht klaren. Wir haben kiirzlich daruber berichtet (3), dass die Steigerung der elektrischen Aktivitat der Grosshirnrinde (Neocortex) bei Hypoventilation wahrscheinlich auf einer Aktivierung des Atemzentrums beruht, doch konnte die Beziehung zwischen beiden Vorgangen nur zum Teil geklart werden. Es wird nun von Versuchen berichtet, die uns der Beantwortung jener Frage naher bringen sollten.

Effects of pentylenetetrazol (PTZ) on conflict behavior were studied using a punished water-lick (conflict) paradigm in rats. PTZ (5-20 mg/kg i.p.) produced a dose-related enhancement of conflict behavior as demonstrated by a suppression of lick responding in low shock intensity (1.3-2 itiA). Furthermore, PTZ (2-20 mg/kg i.p.) markedly antagonized the release of punished responding induced by diazepam (5 mg/kg i.p.), chlordiazepoxide (10 mg/kg i.p.) or meprobamate (75 mg/kg i.p.) when a high intensity of shock (2.5-3 mA) was used. Bemegride also showed a similar suppressive effect on the anticonflict action of diazepam in low doses. However, bicuculline, Picrotoxin or strychnine neither enhanced conflict behavior nor inhibited the anticonflict action of diazepam, even in high doses. In addition, PTZ (10 or 20 mg/kg i.p.) did not alter unpunished drinking or flinch-μMp thresholds, suggesting that the conflict enhancing action of PTZ may not be due to the secondary action, including decrease in drive for drinking or increase in sensitivity to shock. These results suggest that PTZ may exert facilitation of conflict behavior or suppression of the anticonflict action of anxiolytics via activation of the conflict generating mechanisms. A mechanism underlying an induction of convulsion or a GABAergic mechanism may not be involved in the conflict enhancing action of PTZ.