[Repeated Pericardial Effusion Leading to the Diagnosis of Synovial Sarcoma:Report of a Case].

The patient is a 76-year-old man. His chief complaint of chest pain led to a diagnosis of pericardial effusion of unknown cause, and pericardial drainage was performed. On the 30th day, chest pain appeared again. Echocardiography revealed a pericardial fluid reaccumulation and a substantial mass in the pericardial space. Surgical drainage was performed to find the cause. A hematoma/mass was present on the epicardium. The pericardial sac was filled with hematoma. The hematoma was removed, but part of the mass infiltrated close to the anterior descending branch of the left coronary artery, and removal of that part was abandoned. The intrapericardial hematoma and epicardium were submitted to pathology leading to the diagnosis of synovial sarcoma. The patient was discharged home 14 days after surgery.

Percutaneous Intervertebral-Vacuum Polymethylmethacrylate Injection for Foraminal Stenosis with Degenerative Lumbar Scoliosis.

BACKGROUND: Percutaneous intervertebral-vacuum polymethylmethacrylate injection (PIPI) is a minimally invasive procedure for low back pain in elderly patients with degenerative lumbar scoliosis (DLS). Patients with DLS often have radiculopathy as a result of foraminal stenosis in addition to low back pain. The purpose of this study was to evaluate the clinical and radiologic results of PIPI for foraminal stenosis with radiculopathy in elderly patients with DLS. METHODS: We included patients with de novo DLS aged 65 years or older who underwent PIPI. The presence of an intervertebral vacuum on computed tomography and bone marrow edema on magnetic resonance imaging was required for inclusion. The intersegmental radiologic parameters on plain radiographs and computed tomography and the extent of bone marrow edema on magnetic resonance imaging were measured. The clinical outcomes were evaluated using the visual analog scale (VAS) and Oswestry Disability Index (ODI). RESULTS: We enrolled 40 patients with DLS who underwent PIPI. There were 16 men and 24 women, and the mean age was 79.0 ± 6.3 years. The mean foraminal height and extent of bone marrow edema showed a significant increase and reduction, respectively, after PIPI (P < 0.05). VAS score for radiculopathy and ODI significantly improved after PIPI (P < 0.01). The minimum clinically important differences in VAS score for radiculopathy and ODI at the final follow-up were 73.9% and 63.6%, respectively. CONCLUSIONS: PIPI is a minimally invasive procedure not only for low back pain but also for radiculopathy in elderly patients with DLS. It leads to intervertebral stabilization and indirect decompression of the foramen.

Radiographic Factors for Adjacent Vertebral Fractures and Cement Loosening Following Balloon Kyphoplasty in Patients with Osteoporotic Vertebral Fractures.

Introduction: Balloon kyphoplasty (BKP) is a minimally invasive surgical approach for the treatment of osteoporotic vertebral fractures (OVF). Some risks have been reported after treatment with BKP; therefore, it is necessary to determine when BKP does not work. Thus, in this study, we aim to clarify the radiographic predictors of secondary vertebral fractures and cement loosening after BKP for OVF. Methods: This study enrolled patients with single-level OVF at the thoracolumbar junction (T11-L2) who underwent BKP for the first time between January 2011 and March 2014. The clinical outcomes were evaluated using the visual analog scale (VAS) and a modified Oswestry Disability Index (ODI) at 1 week and 1, 3, 6, and 12 months after surgery. Radiographic assessments were performed preoperatively and within 1 year after BKP using plain radiography and computed tomography. Results: The 85 patients who met the inclusion criteria underwent BKP. The average age of participants (21 men, 64 women) was 77.8 years (range, 57-92 years). Postoperative VAS and ODI scores were all significantly better than preoperative scores. Polymethyl methacrylate (PMMA)-cement leakage was observed in 18 patients (21.2%) but was asymptomatic in all cases. Secondary vertebral fractures were detected in 20 patients (23.5%), including adjacent levels in 15 patients (17.6%) and non-adjacent levels in 5 patients (5.9%). Rostral bridging osteophyte formation was found to be significantly associated with the occurrence of adjacent vertebral fractures (odds ratio 12.746; p=0.010). PMMA-cement loosening was observed in three patients (3.5%). A high prevalence (100%) of bridging osteophytes, vacuum clefts, and spinous process fractures was observed in patients with PMMA-cement loosening. PMMA-cement loosening was found in 3 out of 10 patients with all three of these factors. Conclusions: Rostral bridging osteophyte formation was determined to be a risk factor for both adjacent vertebral fractures and PMMA-cement loosening.Level of Evidence: 3.

Prognostic factors for spontaneous spinal epidural hematoma: a multicenter case-control study.

BACKGROUND: To determine the optimal treatment for spontaneous spinal epidural hematoma (SSEH). The aim of this study was to identify factors associated with SSEH. METHODS: In 62 patients with SSEH, several patient-related parameters were analyzed as candidate factors associated with Frankel grade before treatment or at the last follow-up. These parameters were compared between patients with and without surgery. In addition, multivariate ordinal logistic regression analysis was used to identify factors significantly associated with Frankel's grade before treatment or at the last follow-up. RESULTS: There were significant differences in age, location of the hematoma, and Frankel grade before treatment and at the last follow-up between surgical and nonsurgical cases in all patients, but there were no significant differences in any of these parameters when comparing patients with pre-treatment Frankel grade C. The location of the hematoma was significantly associated with the severity of paralysis before treatment. In surgical cases, the time from onset to surgery and the location of the hematoma was significantly associated with the prognosis. When the time from onset to surgery was evaluated using the criteria of 12, 24, and 48 h, 24 and 48 h had a significant impact on the prognosis. In the analysis of nonsurgical cases, only the vertical size of the hematoma was significantly associated with prognosis. CONCLUSION: The time from onset to surgery and the location of the hematoma were prognostic factors in surgical cases, while the vertical size of the hematoma was a prognostic factor in nonsurgical cases.

Estimating the Haemodynamic Streamline Vena Contracta as the Effective Orifice Area Measured from Reconstructed Multislice Phase-contrast MR Images for Patients with Moderately Accelerated Aortic Stenosis.

PURPOSE: In aortic stenosis (AS), the discrepancy between moderately accelerated flow and effective orifice area (EOA) continues to pose a challenge. We developed a method of measuring the vena contracta area as hemodynamic EOA using cardiac MRI focusing on AS patients with a moderately accelerated flow to solve the problem that AS severity can currently be determined only by echocardiography. METHODS: We investigated 40 patients with a peak transvalvular velocity > 3.0 m/s on transthoracic echocardiography (TTE). The patients were divided into highly accelerated and moderately accelerated AS groups according to whether or not the peak transvalvular velocity was ≥ 4.0 m/s. From the multislice 2D cine phase-contrast MRI data, the cross-sectional area of the vena contracta of the reconstructed streamline in the Valsalva sinus was defined as MRI-EOAs. Patient symptoms and echocardiography data, including EOA (defined as TTE-EOA), were derived from the continuity equation using TTE. RESULTS: All participants in the highly accelerated AS group (n = 19) showed a peak velocity ≥ 4.0 m/s in MRI. Eleven patients in the moderately accelerated AS group (n = 21) had a TTE-EOA < 1.00 cm2. In the moderately accelerated AS group, MRI-EOAs demonstrated a strong correlation with TTE-EOAs (r = 0.76, P < 0.01). Meanwhile, in the highly accelerated AS group, MRI-EOAs demonstrated positivity but a moderate correlation with TTE-EOAs (r = 0.63, P = 0.004). MRI-EOAs were overestimated compared to TTE-EOAs. In terms of the moderately accelerated AS group, the best cut-off value for MRI-EOAs was < 1.23 cm2, compatible with TTE-EOAs < 1.00 cm2, with an excellent prediction of the New York Heart Association classification ≥ III (sensitivity 87.5%, specificity 76.9%). CONCLUSION: MRI-EOAs may be an alternative to conventional echocardiography for patients with moderately accelerated AS, especially those with discordant echocardiographic parameters.

Long-term outcome of targeted therapy for low back pain in elderly degenerative lumbar scoliosis.

PURPOSE: Treatment of low back pain (LBP) associated with elderly degenerative lumbar scoliosis (DLS) remains controversial. We have developed percutaneous intervertebral-vacuum polymethylmethacrylate injection (PIPI) targeting to the intervertebral vacuum as a minimally invasive surgery. The present study compared the long-term clinical outcomes of PIPI to that of nonoperative treatment. METHODS: Patients with de novo DLS, aged ≥ 65 years, who had LBP with visual analog scale (VAS) of ≥ 50 for ≥ 6 months with intervertebral vacuum on computed tomography and bone marrow edema (BME) on magnetic resonance imaging were included. The clinical outcomes were evaluated using VAS and the Oswestry Disability Index (ODI) at baseline, 1, 6, 12, 24 months, and at the final follow-up. The course of BME was also evaluated. RESULTS: One hundred and one patients underwent PIPI and 61 received nonoperative treatment. The mean follow-up duration after PIPI and nonoperative treatment was 63.7 ± 32.4 and 43.9 ± 20.9 months, respectively. VAS and ODI after PIPI were significantly improved compared to post-nonoperative treatment. BME decreased substantially in the PIPI group and it was significantly correlated with VAS and ODI improvement. Following PIPI, LBP recurred in 28 patients (35%). LBP recurrence was identified at the same level of PIPI in 10 patients, at the adjacent level of PIPI in 11 patients, and at the non-adjacent level of PIPI in seven patients. Eighteen patients underwent additional PIPIs, and both VAS and ODI were significantly improved after additional PIPIs. CONCLUSION: Bone marrow lesions of the endplate are strongly associated with the presence of LBP. PIPI can be considered as an effective, safe and repeatable treatment for LBP in elderly DLS patients.

Mid- to long-term surgical outcomes of partial anomalous pulmonary venous connection.

OBJECTIVE: To investigate mid- to long-term morbidity and mortality after the repair of partial anomalous pulmonary venous connections (PAPVCs). METHODS: We retrospectively analyzed the cases of 29 consecutive patients who underwent surgery in 1991-2010 at Tokyo Women's Medical University Hospital. Median follow-up period: 9.9 years. Median age at operation: 7.4 years. Median body weight: 22.4 kg. Right PAPVC (n = 23), left-PAPVC (n = 5), and mixed PAPVC (n = 1) were identified. RESULTS: In the 14 patients with a right upper pulmonary vein (PV) connected to the superior vena cava (SVC) and/or cavo-atrial junction, the following were performed: single-patch diversion (n = 6), double-patch diversion (n = 4), Warden procedure (n = 1), and atrial septation with the atrial wall (n = 3). In the nine patients with a right anomalous PV connected to the right atrium (RA) and/or coronary sinus, intra-atrial rerouting was performed (n = 7) and translocation of the atrial septum (n = 2). Intra-atrial rerouting of the left upper and lower PVs to the coronary sinus (n = 1) and direct anastomosis of the left upper PV to the left atrial appendage (n = 4) were performed. Double-patch diversion and direct anastomosis of the left upper PV to the left atrial appendage was performed in a patient with mixed PAPVC. There were no post-operative deaths or reoperations, although transient sinus node dysfunction occurred (n = 2 with atrial septation and intra-atrial rerouting), while mild stenosis of the SVC occurred (n = 1 with double-patch diversion). CONCLUSIONS: The various methods which we used for PAPVC repair all appear to have reasonable outcomes, although rhythm disturbance and stenotic complications were confirmed in a few patients.

Usefulness of endoscopic ultrasound-guided fine-needle biopsy for the diagnosis of autoimmune pancreatitis using a 22-gauge Franseen needle: a prospective multicenter study.

BACKGROUND: Detailed histological evaluation is important in the diagnosis of autoimmune pancreatitis (AIP). However, it remains challenging to obtain adequate tissue from the pancreas. Recently, several reports have suggested the usefulness of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) using the new "core" needles for acquiring pancreatic tissue. We aimed to investigate the usefulness of EUS-FNB for diagnosing AIP with one such needle, a 22-gauge Franseen needle. METHODS: Patients who met the imaging diagnostic criteria for AIP based on the International Consensus Diagnostic Criteria (ICDC) were enrolled in the study. All patients underwent EUS-FNB with a 22-gauge Franseen needle. Histological findings were evaluated based on the ICDC, and the detection rates of level 1 and level 1 or 2 histology were calculated. RESULTS: 56 patients from 11 different institutions were enrolled in the final analysis (55 suspected to have type 1 AIP and one with type 2 AIP). Lymphoplasmacytic infiltration, obliterative phlebitis, storiform fibrosis, and > 10 IgG4-positive cells per high-power field were detected in 55 (100 %), 24 (43.6 %), 40 (72.7 %), and 36 (65.5 %) of the 55 patients, respectively. The detection rates of level 1 and level 1 or 2 histology for AIP were 58.2 % (95 % confidence interval [CI] 44.1 % - 71.3 %) and 92.7 % (95 %CI 82.4 % - 98.0 %), respectively, which were apparently higher than our historical results (7.9 % [95 %CI 1.7 % - 21.4 %] and 62.2 % [95 %CI 46.5 % - 76.2 %], respectively) using a conventional needle. CONCLUSIONS: EUS-FNB with a 22-gauge Franseen needle demonstrated favorable detection rates which would be clinically beneficial for the histological diagnosis of AIP.

[A case of cholinergic crisis with persistent watery diarrhea].

The patient was a 79-year-old man who visited our hospital with the chief complaint of persistent watery diarrhea. This symptom and his general condition aggravated during the planning of colonoscopy, and he was admitted to the intensive care unit. Large-volume fluid replacement, vasopressor administration, and artificial respiration management were performed;however, circulatory dynamics did not improve. Based on his medication history, he was diagnosed with distigmine bromide-induced cholinergic crisis. Atropine sulfate was administered, and his symptoms reduced. On colonoscopy, there were no abnormal findings other than adenoma, and the patient was discharged while in remission.

Early and mid-term outcome of frozen elephant trunk using spinal cord protective perfusion strategy for acute type A aortic dissection.

OBJECTIVE: This study aimed to evaluate the prevalence of spinal cord injury in total arch replacement with frozen elephant trunk for acute type A aortic dissection using our spinal cord protection technique. METHODS: Between January 2013 and December 2017, 33 patients underwent total arch replacement with frozen elephant trunk for acute type A aortic dissection (mean age 67.9 ± 13.3 years). Our spinal cord protection technique involved maintaining extracorporeal circulation through the left subclavian artery in all procedures, using aortic occlusion balloon during distal anastomosis, and inserting frozen elephant trunk above Th 8 with transesophageal echocardiographic guidance. Computed tomography was performed within 1-2 weeks, 12 months, and 36 months postoperatively. We compared the degree of thrombosis of the descending aorta between preoperation and early postoperative period by Fisher's exact test. Moreover, we evaluated postoperative mortality and mobility (including spinal cord injury) at follow-up. RESULTS: The operative mortality within 30 days was 6.1%. Neither paraplegia nor paraparesis was noted. We observed significant thrombosis of the false lumen at the distal arch and aortic valve level of the descending aorta in postoperative early term period (p < 0.01). At mid-term follow-up (mean 33.9 months), survival probability and 3-year freedom from reoperation rates were 93.9 ± 4.1% and 95.0 ± 4.9%, respectively. CONCLUSIONS: The frozen elephant trunk technique with our spinal protection strategy provides good postoperative outcomes. Our strategy can maintain spinal cord perfusion without complete ischemia time even during lower body ischemia time. Implementation of our spinal protection strategy will help prevent spinal cord injury and dilated downstream aorta.

Long-term outcomes of Ross and Ross-Konno operations in patients under 15 years of age.

OBJECTIVE: The Ross operation is an excellent surgical option for young children, regardless of aortic pathology type. However, failure rates are concerning during the second postoperative decade. We sought to determine the predictors of long-term outcomes after Ross and Ross-Konno operation performed in childhood. METHODS: We performed 34 Ross and 9 Ross-Konno operations in pediatric patients (age < 15 years) from 1996 to 2016, and retrospectively evaluated the long-term results. RESULTS: The postoperative follow-up period was 13.5 ± 3.9 years. In the Ross group, there were one inpatient death and one death after discharge. There were no inpatient deaths in the Ross-Konno group. There were 6 reoperations in the Ross group and 1 in the Ross-Konno group for left ventricular outflow tract (LVOT). Cumulative survival rates were 96.8% and 100% in the Ross and Ross-Konno groups, respectively. The reoperation free rate for LVOT /RVOT (right ventricular outflow tract) were 98.6/85.5% and 91.9/63.4% in the 5th and 10th years of follow-up, respectively. Patients who underwent the operations at age > 8.6 years had higher risks of reoperation for LVOT. Aortic annulus measurements > 24 mm or aorta/pulmonary artery diameter (Ao/PA) ratios > 1.2 conferred higher risks of reoperation for LVOT. CONCLUSIONS: Long-term outcomes after Ross and Ross-Konno operations in children were satisfactory. However, new-onset aortic regurgitation was progressive and reoperation was needed in some children. Age, aortic annulus diameter, and Ao/PA ratio may be able to predict of long-term outcomes after Ross and Ross-Konno operations.

Randomized Phase II Study of Consecutive-Day versus Alternate-Day Treatment with S-1 as Second-Line Chemotherapy in Advanced Pancreatic Cancer.

OBJECTIVE: To evaluate the efficacy and safety of alternate-day administration of S-1 as second-line chemotherapy for unresectable pancreatic cancer in a multicenter, randomized, phase II study. METHODS: Patients with histologically proven, unresectable pancreatic cancer treated with chemotherapy not including S-1 as first-line therapy were randomly assigned to receive either daily or alternate-day treatment with S-1. The primary end point was overall survival (OS), and the secondary end points were progression-free survival (PFS), time to treatment failure (TTF), response rate, and adverse events. RESULTS: A total of 77 patients were enrolled, of which 75 were included in the final analysis. The median OS was 4.5 months in the daily group and 4.4 months in the alternate-day group (HR 1.178; 95% CI 0.741-1.875), with no significance in PFS and TTF. The response rate was 2.8% in the daily group and 0% in the alternate-day group. Grade 3 or higher adverse events occurred with significantly higher incidence in the daily group (47.2 vs. 25.6%, p = 0.044). CONCLUSION: As a second-line chemotherapy for unresectable pancreatic cancer, although the efficacy in both groups was comparable and we can expect fewer toxicities with alternate-day administration of S-1, the noninferiority of alternate-day treatment to daily treatment with S-1 was not verified.

Surgical Strategies for Type B Aortic Dissection by Frozen Elephant Trunk.

The timing and choice of surgical method for type B aortic dissection, is still a topic of much debate. We performed total arch replacement using frozen elephant trunk (TAR-FET) as a means of preventing distant aortic events, such as retrograde type A aortic dissection (RTAD). We conducted analysis of 142 patients with acute type B dissection who were admitted between January of 2010 and July of 2017. Fifty-five cases required surgical intervention to treat enlargement of the false lumen diameter and ULP formation 2 weeks after the onset of symptoms. 17 TAR-FET were performed with a mean of 42±26 days period from onset to surgery. There were no complications of RTAD or paraplegic, and 90% of patient demonstrated aortic event free survival (5 years) and false lumen reduction ratio of 35%. Based on our analysis, using TAR-FET properly avoids serious complications like RTAD, and is a viable treatment option for type B dissection. (This is a translation of J Jpn Coll Angiol 2018; 58: 151-157.).

Modified Double Patch Repair for Septal Rupture With Ventricular Wall Dissection.

Ventricular septal rupture with ventricular free wall dissection is an extremely rare complication after inferior myocardial infarction, and the optimal surgical strategy remains unclear because of the limited number of survival cases. Electrocardiography-synchronized contrast computed tomography was performed before surgery to identify the dissected area and to set up a surgical strategy. We report on modified double patch repair with ventricular wall dissection exclusion, which might be effective for preventing residual shunt and maintaining cardiac function.

Twenty-year experience with the Konno operation: Konno incision does not impair LV function.

BACKGROUND: There has been no report observing the LV function of Konno incision. We examined the outcomes of the Konno operations over 20 years. METHODS: We investigated 63 Konno operations with mechanical valves performed from 1984. This study aimed to evaluate the effects of Konno incision including LV function changes and the long-term outcomes of patient survival and reoperation rate (RVOT and LVOT complications). RESULTS: The postoperative follow-up period was 20.6 ± 6.2 years. Early death occurred in 1 case and late death occurred in 9 cases. The cumulative survival rate was 89.6, 87.5, and 84.5% in the 5th, 10th, and 20th follow-up years. Five patients required reoperation for the aortic valve. The recurrence avoidance rate for LVOT reoperation was 96.6, 94.7, and 92% in the 5th, 10th, and 20th follow-up years of the Konno operation. Konno incision did not show significant decline in postoperative LV ejection fraction. (Pre, 62% vs 20 years later, 58%; P = 0.052.) There were no cases requiring intervention at the event of ventricular arrhythmia, but 13 cases were Complete Right bundle branch block, and 11 cases were Left bundle branch block. CONCLUSIONS: The survival rate associated with Konno operation throughout 20 years was excellent. Konno incision can secure sufficient LV outflow tract and is a safe treatment for complex LVOTO without deteriorating LV ejection fraction.

Modified double patch repair with infarct exclusion technique for ventricular septal perforation: a case study.

BACKGROUND: Ventricular septal perforation (VSP) after acute myocardial infarction (AMI) is accompanied by the worsening of rapid hemodynamics, resulting in a poor prognosis. In our department, infarct lesions are preoperatively detected with electrocardiogram (ECG)-synchronized contrast computed tomography, and the scope of approach and exclusion is determined. Furthermore, to effectively prevent a residual shunt, modified double patch repair and infarct exclusion techniques were used in combination to preserve left ventricular (LV) function. This method is reported because it considers both techniques as a surgical procedure that can be accomplished relatively easily and simultaneously. CASE PRESENTATION: We targeted two consecutive VSP patients who underwent this procedure. It took an average of 1 day from the onset of VSP to surgery. We performed double patch and infarct exclusion for VSP using bovine pericardium via an LV incision. Two patches were marked with a skin pen to anastomose eight mattresses equally. In addition, a one piece-coupled patch was made for infarct exclusion. The two patients were extubated on the day after surgery and intra-aortic balloon pump assistance was also withdrawn. Without perioperative complications, they could leave the intensive care unit after 6.5 days on average. Early postoperative ECG and magnetic resonance angiography showed good LV wall contraction, except at the infarcted area, with no evidence of a residual shunt. CONCLUSION: The modified double patch repair with infarct exclusion technique is more effective for preventing a residual shunt and maintaining postoperative cardiac function than either of the techniques alone.

Endocardial linear infarct exclusion technique for non-ischaemic functional mitral regurgitation caused by cardiac sarcoidosis: a case report.

INTRODUCTION: Damage to the posterior wall of the left ventricle (LV) can cause tethering mitral regurgitation (MR). We present a patient with non-ischaemic tethering MR and congestive heart failure due to cardiac sarcoidosis who was treated using an endocardial linear infarct exclusion technique. CASE PRESENTATION: A 63-year-old woman with a history of uveitis presented to our hospital complaining of dyspnoea. Echocardiography revealed dyskinesis of the posterolateral wall of the LV and severe tethering MR (regurgitation volume: 92 mL). The LV ejection fraction was reduced to 45%. Cardiac catheterization revealed no stenosis. Magnetic resonance imaging with late gadolinium enhancement revealed a contrast effect and thinning of the posteriolateral wall. The abnormal accumulation was also observed with fluorodeoxyglucose-positron emission tomography. Together, these findings indicated cardiac sarcoidosis, and we determined that cardiac sarcoidosis had resulted in aneurysm development in the posterior wall of the LV, subsequent advanced tethering at the posterior mitral valve cusp, and severe functional MR. The patient underwent an endocardial linear infarct exclusion technique (ELIET), mitral annuloplasty, tricuspid annuloplasty, and the full MAZE procedure. Histopathological analysis of the posterior wall myocardium revealed marked thinning of the endocardium, replacement fibrosis, lymphocyte infiltration, and epithelialization. These findings were consistent with sarcoidosis. The patient's condition improved to New York Heart Association (NYHA) Class I, and cardiac events were rare at 6 months after surgery. DISCUSSION: Endocardial linear infarct exclusion technique is useful for treating tethering MR. To our knowledge, this is the first reported case of successful treatment using ELIET for non-ischaemic tethering MR caused by cardiac sarcoidosis.

Long-term Effect of Enlargement of a Ventricular Septal Defect in the Rastelli Procedure.

We investigated the effect of ventricular septal defect (VSD) enlargement on long-term surgical results, late arrhythmia, and left ventricular (LV) function in the Rastelli procedure for D-transposition of the great arteries with LV outflow tract obstruction (LVOTO). From 1979 to 2001, 74 patients (D-transposition of the great arteries, n = 56; double outlet right ventricle, n = 18) underwent the Rastelli procedure. In group A, 46 patients underwent the Rastelli procedure with VSD enlargement, and in group B, 28 patients underwent the Rastelli procedure without enlargement. There were no hospital deaths. Actuarial survival at 20 years was 80% in group A and 91% in group B (P = 0.50). Freedom from reoperations at 20 years was 40.1% in group A and 52.0% in group B. Reoperations for LVOTO were performed in 2 patients in both groups. In postoperative catheterization, LV ejection fraction in group A was 57.1% ± 8.7% vs 57.2% ± 8.1% in group B (P = 0.97); LV end-diastolic volume, 150.0% ± 47.2% vs 142.0% ± 36.9% of the normal volume (P = 0.97). In long-term postoperative echocardiography, the pressure gradient of the LV to the aorta was 12.0 ± 12.8 vs 17.7 ± 26.0 mm Hg in groups A and B (P = 0.31). There were no differences between the groups regarding basal rhythms, anti-arrhythmic agents, and pacemaker implantation rate. VSD enlargement in the Rastelli procedure can be safely performed without early mortality and with long-term low mortality and morbidity regarding arrhythmia, LV function, and reoperation for late LVOTO. VSD enlargement should be considered as an option for avoiding long-term LVOTO.

Long-term follow-up of Fontan completion in adults and adolescents.

BACKGROUND: The Fontan procedure is rarely performed in adults and adolescents in the present era. We review our results with the Fontan procedure in adolescents and young adults. METHODS: Between 1974 and 2010, 79 consecutive patients underwent the Fontan procedure at an age ≥ 15 years (mean age at Fontan operation, 20.3 years ± 4.5 years). Forty-five patients underwent atriopulmonary connection, 11 underwent the Bjork procedure, and 23 underwent total cavopulmonary connection. RESULTS: Ten hospital deaths (HDs) and/or early Fontan takedowns (TDs) occurred. The median follow-up period was 18.2 years (range, 0.6-37.6 years). The estimated freedom from death or TD rates was 79.7% at 5 years, 77.0% at 10 years, 73.9% at 15 years, and 63.9% at 20 years. Age was not a predictor of HD and/or TD. Freedom from death or TD after 1998 was 69.1% at 5 years, 69.1% at 10 years, and 69.1% at 15 years, and before 1997 was 82.3% at 5 years, 79.0% at 10 years, 75.5% at 15 years, and 65.1% at 20 years; there were no significant differences between the two groups. In 19 late-death patients, nine (47.4%) experienced sudden death. Among these patients, five had known arrhythmias before sudden death. CONCLUSIONS: In patients who were ≥15 years old, the surgical results of the Fontan operation were acceptable. Approximately half of the late deaths were sudden deaths, mainly occurring 10-20 years postoperatively.

Relationship between clinical symptoms of osteoporotic vertebral fracture with intravertebral cleft and radiographic findings.

BACKGROUND: With aging of the population, the numbers of osteoporotic vertebral fractures with intravertebral cleft have been increasing. However, the details of clinical symptoms of osteoporotic vertebral fractures with intravertebral cleft are poorly understood. The purpose of this study was to evaluate the relationship between clinical symptoms of osteoporotic vertebral fractures with intravertebral cleft and radiographic findings. METHODS: Two hundred seventeen patients with single-level osteoporotic vertebral fractures with intravertebral cleft were examined. Clinical symptoms were evaluated using Numerical Rating Scale for back pain and the Oswestry Disability Index for physical disability. The presence of delayed neurologic deficit was also detected. Radiography and computed tomography were used to measure local kyphotic angle and vertebral instability and to detect the presence of posterior wall fracture of the vertebral body. Correlations between clinical symptoms of osteoporotic vertebral fractures with intravertebral cleft and radiographic findings were investigated. RESULTS: Mean Numerical Rating Scale and Oswestry Disability Index were 7.4 and 58.0%, respectively. Delayed neurologic deficit occurred in 41 patients (19%). The mean local kyphotic angle, vertebral instability, and rate of posterior wall fracture of the vertebral body were 19.4°, 7.3°, and 91%, respectively. Numerical Rating Scale and Oswestry Disability Index were statistically correlated with vertebral instability but not with local kyphotic angle and presence of posterior wall fracture. In the patients with delayed neurologic deficit, vertebral instability was significantly higher and posterior wall fractures were significantly more frequent than in the patients without delayed neurologic deficit. Local kyphotic angle was not correlated with delayed neurologic deficit. CONCLUSIONS: Vertebral instability is a factor causing symptoms of osteoporotic vertebral fractures with intravertebral cleft. In addition, vertebral instability may be the predominant cause of delayed neurologic deficit. To manage osteoporotic vertebral fractures with intravertebral cleft and delayed neurologic deficit efficiently, it may be important to control vertebral instability of osteoporotic vertebral fractures.