Pulsatile thrombus evacuation from the false lumen of an occluded carotid artery in acute aortic dissection.

Herein, we present a case of aortic dissection with right carotid artery occlusion that was treated successfully with thrombus evacuation from the false lumen of the occluded carotid artery during hemiarch replacement. This procedure is performed with two maneuvers: aggressive retrieval of the thrombus from the innominate artery during circulatory arrest and thrombus evacuation from the false lumen of the right common carotid artery through a right neck incision with the heart beating. In this alternative method, thrombi can be evacuated more naturally and briskly, using pulsatile flow.

IgG index of cerebrospinal fluid can reflect pathophysiology associated with Lewy bodies in Parkinson's disease.

BACKGROUND: Neuroinflammation is one of the pathophysiologies of Parkinson's disease (PD). Lewy bodies, the pathological hallmark of PD, emerge as a consequence of α-synuclein aggregation, and neuroinflammation is induced concurrently with this aggregation. Imaging and cerebrospinal fluid (CSF) biomarkers that reflect PD pathophysiology have been developed or are under investigation. The IgG index of CSF is a marker of inflammation, and may also reflect the pathophysiology of PD. AIM: We examined if the IgG index reflects the pathophysiology of PD in drug-naïve PD patients. METHOD: The subjects were 20 consecutive PD patients who underwent 123I-MIBG scintigraphy for assessment of the heart to mediastinum (H/M) ratio and wash out rate, 123I-Ioflupane SPECT for examination of the specific binding ratio in the striatum, and lumbar puncture before treatment. The CSF IgG index and levels of pathogenic proteins (total α-synuclein, oligomeric α-synuclein, total tau, phosphorylated tau and amyloid Aß1-42) were determined. The IgG index was compared with the other parameters using Spearman correlation analysis. RESULTS: The IgG index showed a significant correlation with the H/M ratio in early (r = -0.563, p = 0.010) and delayed (r = -0.466, p = 0.038) images in 123I-MIBG scintigraphy and with the CSF total tau level (r = -0.513, p = 0.021). CONCLUSION: Neuroinflammation is involved in PD pathophysiology in some patients, and a higher IgG index indicates the presence of neuroinflammation accompanied by emergence of Lewy bodies.

Worsening Isolated Superior Mesenteric Artery Dissection on the Day After Discharge.

A 59-year-old male was transported to the emergency department by ambulance with complaints of left-sided abdominal pain. Blood gas analysis revealed elevated lactate, and plain computed tomography revealed no bowel ischemic change. Contrast-enhanced computed tomography revealed isolated superior mesenteric artery dissection with mildly stenosed true lumen. The patient was treated with conservative management on admission. Staged fluid intake, oral prescriptions, and diet were commenced with attention to the symptoms. After four days of hospitalization, the patient was discharged with a stable condition. However, the patient returned to our hospital complaining of left lower back pain three hours after discharge. Contrast-enhanced computed tomography revealed an enlarged false lumen with a moderately stenosed true lumen. After a thorough discussion between vascular surgeons and interventional radiologists, conservative management was commenced on the second admission. The clinical course was uneventful, with proof of improved imaging findings.

Posterior Mitral Leaflet (PML) Perforation due to Infective Endocarditis (IE) Complicated with Cerebral Infarction.

A 64-year-old man on dialysis presented to the emergency department with a fever and chills. Transthoracic echocardiography (TTE) showed small vegetation on the posterior mitral leaflet (PML). Antibiotic therapy was initiated. Two weeks later, right hemiparesis occurred. MRI of the head showed occlusion of the left middle cerebral artery, which suggested an embolism derived from the vegetation. The patient was then referred to the department of cardiovascular surgery. Transesophageal echocardiography (TEE) revealed perforation of the PML and severe mitral regurgitation (MR). The patient underwent mitral valve repair. The postoperative course was uneventful, and the patient was discharged after six weeks of antibiotic treatment. A fresh autologous pericardium is the material of choice to repair the valve.

Posterior Mitral Leaflet Prolapse and Subsequent Mitral Valve Endocarditis Complicated With Anterior Leaflet Perforation.

A 68-year-old male presented with a two-week history of fever, and further investigations revealed mitral valve endocarditis caused by Staphylococcus epidermidis, with associated severe mitral regurgitation (MR). The patient was referred for mitral valve surgery but developed new neurological symptoms two days before the operation, which were diagnosed as symptomatic epilepsy. During surgery, kissing lesions were found on the posterior mitral leaflet (PML), which were not detected on preoperative transesophageal echocardiography (TEE). Mitral valve repair was completed using autologous pericardium. The current case highlights the importance of careful examination of leaflets during surgery and not relying solely on preoperative imaging to detect all lesions. It is essential to promptly diagnose and treat infective endocarditis to prevent further complications and ensure successful outcomes.

Management of Coronary Artery Bypass Grafting Using an Arteriovenous Fistula: An Intraoperative Change in the Preoperative Plan.

Regarding coronary artery bypass grafting (CABG) in patients on hemodialysis, in situ internal thoracic artery (ITA) grafting of the left anterior descending artery (LAD) improves survival and freedom from cardiac events. Although a problem with the ITA can possibly occur, using the ITA ipsilateral to an arteriovenous fistula (AVF) in the upper extremity of patients on hemodialysis can cause coronary subclavian steal syndrome (CSSS). CSSS is a condition of myocardial ischemia caused by the diversion of blood flow from the ITA following coronary artery bypass surgery. CSSS has been reported to occur in cases of subclavian artery stenosis, AVF, and low cardiac function. A 78-year-old man with end-stage renal disease experienced angina pectoris during hemodialysis. The patient was scheduled for CABG, including anastomosis of the left internal thoracic artery (LITA) and LAD. After completion of all anastomoses, the LAD graft demonstrated retrograde blood flow, suggestive of ITA anomalies or CSSS. The LITA graft was transected at the proximal part and anastomosed to the saphenous vein graft with sufficient flow to the high lateral branch eventually.

Partial Arch Replacement Using Common Trunk Perfusion in Type A Acute Aortic Dissection.

An 80-year-old woman was referred to our hospital following a syncope. Contrast-enhanced computed tomography revealed an acute type A aortic dissection with a bovine aortic arch and an enlarged innominate artery. The dissection affected only the ascending aorta and not the common trunk, which is composed of the innominate and left common carotid arteries. Cardiopulmonary bypass was established using common trunk perfusion and vena cava drainage. Following a thorough evaluation, a surgical intervention involving the replacement of the ascending aorta and partial arch, accompanied by the excision of the dilated innominate artery, was meticulously carried out. In instances where the common trunk remains unaffected by the dissection, it presents as a viable alternative perfusion site. Therefore, opting for an approach involving the resection of the common trunk followed by the separate reconstruction of the innominate and left common carotid arteries during the replacement of the ascending aorta and partial arch may serve as a preventative measure against potential vascular events in the future.

Cerebral white matter lesions and regional blood flow are associated with reduced cognitive function in early-stage cognitive impairment.

Background: Differences in the extent of cerebral white matter lesions (WML) and regional cerebral blood flow (rCBF) in early-stage cognitive impairment (ESCI) contribute to the prognosis of cognitive decline; however, it is unclear precisely how WML and rCBF affect cognitive decline in ESCI. Objective: We examined the association between WML, rCBF, and cognitive impairment in the ESCI, using path analysis to clarify how these variables affect each other. Methods: Eighty-three patients who consulted our memory clinic regarding memory loss were included in this study based on the Clinical Dementia Rating. Participants underwent the Mini-Mental State Examination (MMSE), brain magnetic resonance imaging (MRI) for voxel-based morphometry analysis, and brain perfusion single-photon emission computed tomography (SPECT) for rCBF evaluation in cortical regions, using 3D stereotactic surface projection (3D-SSP) analysis. Results: Path analysis was performed on the MRI voxel-based morphometry and SPECT 3D-SSP data, showing a significant correlation between both and MMSE scores. In the most suitable model (GFI = 0.957), correlations were observed between lateral ventricular (LV-V) and periventricular WML (PvWML-V) volumes [standardized coefficient (SC) = 0.326, p = 0.005], LV-V and rCBF of the anterior cingulate gyrus (ACG-rCBF; SC = 0.395, p < 0.0001), and ACG-rCBF and PvWML-V (SC = 0.231, p = 0.041). Furthermore, a direct relationship between PvWML-V and MMSE scores was identified (SC = -0.238, p = 0.026). Conclusion: Significant interrelationships were observed among the LV-V, PvWML-V, and ACG-rCBF that directly affected the MMSE score in the ESCI. The mechanisms behind these interactions and the impact of PvWML-V on cognitive function require further investigation.

Propensity score analysis comparing off-pump versus on-pump coronary artery bypass grafting in older adults.

OBJECTIVE: This study aimed to compare the results of off-pump and on-pump coronary artery bypass grafting in older adults and to examine early and late outcomes. METHODS: This study included 226 patients aged ≥ 75 years who underwent isolated coronary artery bypass grafting. Of these, 141 and 85 patients were included in the off-pump and on-pump groups, respectively. Propensity scores were calculated for each case, matched, and compared between the two groups (68 cases in each group), along with mid-term outcomes of survival and major adverse cardiac events. RESULTS: Operative time, red blood cell transfusion volume, and postoperative hospital stay duration were significantly higher in the on-pump group (267 vs 370 min, P < 0.001; 4.3 vs 17.2 units, P < 0.001; and 20.8 vs 35.8 days, P = 0.012, respectively). Postoperative occurrence of new atrial fibrillation was significantly higher in the on-pump group (4.4% vs 27.9%, P < 0.001), and Kaplan-Meier survival analysis showed a significantly worse prognosis in the on-pump group than in the off-pump group (3-year survival rate 90.7% vs 71.5%, log rank P = 0.007). However, there was no statistically significant difference in cardiovascular-related deaths (log rank P = 0.07). CONCLUSIONS: On-pump coronary artery bypass grafting in an older adult population resulted in increased transfusion volume and postoperative occurrence of atrial fibrillation. The mid-term postoperative outcomes were also poorer with on-pump coronary artery bypass grafting. Off-pump coronary artery bypass grafting reduced future all-cause deaths in older adults.

Retrograde Type A Acute Aortic Dissection With Cerebral Malperfusion Six Years After Thoracic Endovascular Aortic Repair.

A 59-year-old male with prior thoracic endovascular aortic repair presented with altered mental status. Magnetic resonance imaging showed cerebral infarction, and subsequent computed tomography revealed acute type A aortic dissection and right carotid artery occlusion. He underwent total arch replacement with right carotid artery bypass. After successful intervention, he was transferred to a rehabilitation facility for further improvement.

Determining Infected Aortic Aneurysm Treatment Using Focused Detection of Helicobacter cinaedi.

We detected Helicobacter cinaedi in 4 of 10 patients with infected aortic aneurysms diagnosed using blood or tissue culture in Aichi, Japan, during September 2017-January 2021. Infected aortic aneurysms caused by H. cinaedi had a higher detection rate and better results after treatment than previously reported, without recurrent infection.

Sudden Cardiac Arrest Due to Spontaneous Coronary Artery Rupture - A Case Report with a Diagnostic Challenge.

Spontaneous coronary artery rupture (SCAR) is a rare, life-threatening disease, and the diagnosis is often challenging. We herein report a 70-year-old man who suffered sudden cardiac arrest due to SCAR with pericardial fluid. At first, emergent coronary angiography (CAG) failed to detect abnormalities. The emergent operation revealed that the presence of pericardial fluid was caused by bleeding that had spontaneously occurred at the left circumflex artery (LCx). A careful retrospective CAG review showed slight contrast spillage from the distal LCx. SCAR should be suspected in patients with unknown etiology of pericardial effusion, and careful inspection of CAG is necessary.

Aortic Arch Enlargement and Coarctation Repair of Preserving the Lesser Curvature of the Aortic Arch Through a Left Thoracotomy in Neonates.

The aim of this study was to analyze the aortic arch repair technique for preserving the lesser curvature without cardiopulmonary bypass through a left thoracotomy in neonates with coarctation of the aorta (CoA) and a hypoplastic distal aortic arch (HDAA). HDAA was defined as z-score of the aortic arch < - 2.5. Twenty-four neonates with CoA and HDAA were retrospectively studied. Patients underwent enlargement of the HDAA associated with CoA repair when their z-scores were < - 4. They were divided into 2 groups on the basis of the preoperative z-score of the distal aortic arch: group 1 (n = 14), z-score ≥ - 4; group 2 (n = 10), z-score < - 4. Twenty-two patients had intracardiac defects. Follow-up ranged from 0.9 to 20.1 years (median 11.6 years). The z-scores of the distal aortic arch were significantly smaller in group 2 than group 1 (- 5.09 ± 1.05 vs - 3.19 ± 0.36, p < 0.001). There were no hospital deaths and no hypertension. All dimensions of the aortic arch in both groups revealed significant catch-up growth (p < 0.02). All patients showed a pressure gradient ≤ 5 mmHg across the aortic arch and between the arms and legs at the latest follow-up. Two patients showed an angulated arch deformity over 10 years later. This technique provided good catch-up growth and a low incidence of reobstruction and deformity of reconstructed aortic arch in both groups. These results suggest that this modification might be considered as one choice of technique for CoA and HDAA.

Usefulness of the advanced monoenergetic image reconstruction in dual-energy computed tomography for detecting the perforator vein of lower extremity varix.

BACKGROUND: Identification of the perforator vein is important for treating lower extremity varix. PURPOSE: We evaluated the ability of 40-keV advanced monoenergetic images to depict the perforator vein in patients with lower extremity varix. MATERIAL AND METHODS: Thirty-three patients aged 52-86 years were examined with contrast-enhanced dual-energy computed tomography (CT) and advanced virtual monoenergetic images (40 keV) were reconstructed. For evaluating enhancement of a lower extremity vein and the difference in CT number between the vein and muscle, we set the region of interest on the popliteal vein (PV). We also evaluated the ability of 100-kVp and 40-keV volume-rendering (VR) images to depict the perforator veins. RESULTS: The mean CT numbers of the PV at 100 kVp and 40 keV were 113 ± 16 and 321 ± 63 HU, respectively (P < 0.01). In 40-keV transverse images of 33 patients, 84 of the perforator veins were detected. In those 84 veins, 70 (83%) were depicted and 14 (17%) were not depicted on VR images that were reconstructed from 40-keV transverse images. At 100 kVp, 10 (12%) of the perforator veins could be depicted in VR images because the muscles buried them or the PVs were blurred due to insufficient enhancement. CONCLUSION: The advanced monoenergetic reconstruction technique is useful for evaluating the perforator vein in patients with lower extremity varix.

Aortic valve replacement via a right parasternal approach in a patient with a history of coronary artery bypass surgery and pericardiectomy: a case report.

BACKGROUND: The number of patients who require aortic valve replacement after coronary artery bypass grafting continues to increase. Re-operative cardiovascular surgery after coronary artery bypass grafting has various risk factors related to median re-sternotomy. It is particularly essential to avoid damage to the living graft. We successfully performed aortic valve replacement via right parasternal thoracotomy in a patient who had undergone coronary artery bypass grafting. CASE PRESENTATION: An 80-year-old man who had undergone coronary artery bypass grafting was referred to our hospital for syncope caused by severe aortic valve stenosis. He also had a history of pericardiotomy for constrictive pericarditis. His left internal thoracic artery bypass graft was patent. Aortic valve replacement was performed through a small right parasternal thoracotomy during cardiac arrest following cardiopulmonary bypass under moderate hypothermia and hyperkalemia by intermittent selective antegrade cardioplegia. His postoperative course was uneventful. CONCLUSION: Aortic valve replacement via right parasternal thoracotomy with moderate hypothermia and hyperkalemia was safe and effective for avoidance of re-sternotomy-related complications.

Staged coil embolization after thoracic endovascular stent grafting for aneurysmal chronic type B aortic dissection: A case report.

We herein describe a 38-year-old woman with Marfan syndrome and chronic type A aortic dissection. Computed tomography showed that the sinus of Valsalva and thoracoabdominal aorta had a diameter of 62 and 55 mm, respectively. After 7 months of a Bentall operation and total arch replacement with the elephant trunk technique, we performed thoracic endovascular aortic repair for an aneurysm of the descending aorta, but we preserved the retrograde flow into the false lumen because it supplied vessels perfusing the spinal cord. Computed tomography angiography 14 months after thoracic endovascular aortic repair showed that the thoracic aortic diameter had increased to 68 mm. We then performed partial (proximal only) coil embolization of the false lumen. After 6 months, the thoracic aortic diameter had decreased to 60 mm and the spinal cord remained perfused via the distal false lumen. Staged coil embolization after thoracic endovascular aortic repair for aneurysmal chronic type B aortic dissection is feasible and can be beneficial.

Prognostic Risk Analyses for Postcardiotomy Extracorporeal Membrane Oxygenation in Children: A Review of Early and Intermediate Outcomes.

We evaluated the morbidity and mortality of children requiring postcardiotomy extracorporeal membrane oxygenation (ECMO) to determine independent factors affecting early and intermediate outcomes. Between January 2002 and December 2015, 79 instances of ECMO after cardiac surgery in 73 children were retrospectively reviewed. Follow-up was completed in December 2016. Predictive risk analyses were employed concerning weaning of ECMO, hospital discharge, and mortality after discharge. Age and weight were 14.9 ± 25.6 months and 7.0 ± 5.3 kg, respectively. Median support time was 8.3 ± 4.4 days. Sixty-seven (85%) were successfully weaned off ECMO and 48 (61%) survived to hospital discharge. Multi-variate logistic regression analysis identified the first day to obtain negative fluid balance after initiation of support (adjusted odds ratio = 0.42), high serum lactate levels (0.97), and high total bilirubin (0.84) during support as significant independent factors associated with successful separation from ECMO. The first day of negative fluid balance (0.65) after successful decannulation was an independent risk factor for survival to hospital discharge. After hospital discharge, actuarial 1-year, 5-year, and 10-year survival rates were 94%, 78%, and 78%, respectively. Low weight increased the risk of death after hospital discharge by a multi-variate Cox hazard model. High serum lactate, high serum bilirubin, and unable to obtain early negative fluid balance during support impacted mortality of decannulation. Obtaining a late negative fluid balance in post-ECMO were independent risk factors for death after successful weaning. Low weight affected intermediate outcomes.

Sequence and intramolecular distance scoring analyses of microbial rhodopsins.

Recent accumulation of sequence and structural data, in conjunction with systematical classification into a set of families, has significantly advanced our understanding of diverse and specific protein functions. Analysis and interpretation of protein family data requires comprehensive sequence and structural alignments. Here, we present a simple scheme for analyzing a set of experimental structures of a given protein or family of proteins, using microbial rhodopsins as an example. For a data set comprised of around a dozen highly similar structures to each other (overall pairwise root-mean-squared deviation < 2.3 Å), intramolecular distance scoring analysis yielded valuable information with respect to structural properties, such as differences in the relative variability of transmembrane helices. Furthermore, a comparison with recent results for G protein-coupled receptors demonstrates how the results of the present analysis can be interpreted and effectively utilized for structural characterization of diverse protein families in general.

Effectiveness of cardiac surgery in patients with trisomy 18: a single-institutional experience.

BACKGROUND: Surgical repair for cardiac lesions has rarely been offered to patients with trisomy 18 because of their very short lifespans. We investigated the effectiveness of cardiac surgery in patients with trisomy 18. Patients and methods We performed a retrospective analysis of 20 consecutive patients with trisomy 18 and congenital cardiac anomalies who were evaluated between August, 2003 and July, 2013. All patients developed respiratory or cardiac failure due to excessive pulmonary blood flow. Patients were divided into two subgroups: one treated surgically (surgical group, n=10) and one treated without surgery (conservative group, n=10), primarily to compare the duration of survival between the groups. RESULTS: All the patients in the surgical group underwent cardiac surgery with pulmonary artery banding, including patent ductus arteriosus ligation in nine patients and coarctation repair in one. The duration of survival was significantly longer in the surgical group than in the conservative group (495.4±512.6 versus 93.1±76.2 days, respectively; p=0.03). A Cox proportional hazard model found cardiac surgery to be a significant predictor of survival time (risk ratio of 0.12, 95% confidence interval 0.016-0.63; p=0.01). CONCLUSIONS: Cardiac surgery was effective in prolonging survival by managing high pulmonary blood flow; however, the indication for surgery should be carefully considered on a case-by-case basis, because the risk of sudden death remains even after surgery. Patients' families should be provided with sufficient information to make decisions that will optimise the quality of life for both patients and their families.

Image quality at low tube voltage (70 kV) and sinogram-affirmed iterative reconstruction for computed tomography in infants with congenital heart disease.

BACKGROUND: Lower tube voltage has advantages for CT angiography, such as improved contrast OBJECTIVE: To evaluate the image quality of low-voltage (70 kV) CT for congenital heart disease and the ability of sinogram-affirmed iterative reconstruction to improve image quality. MATERIALS AND METHODS: Forty-six children with congenital heart disease (median age: 109 days) were examined using dual-source CT. Scans were performed at 80 kV and 70 kV in 21 and 25 children, respectively. A nonionic iodinated contrast medium (300 mg I/ml) was used for the 80-kV protocol. The contrast medium was diluted to 75% (225 mgI/mL) with saline for the 70-kV protocol. Image noise was measured in the two protocols for each group by extracting the standard deviations of a region of interest placed on the descending aorta. We then determined whether sinogram-affirmed iterative reconstruction reduced the image noise at 70 kV. RESULTS: There was more noise at 70 kV than at 80 kV (29 ± 12 vs 20 ± 4.8; P < 0.01). Sinogram-affirmed iterative reconstruction with grade 4 strength settings improved the noise (20 ± 5.9; P < 0.01) for the 70-kV group. CONCLUSION: Sinogram-affirmed iterative reconstruction improved the image quality of CT in congenital heart disease.