Configuration of the neoaortic root after chimney reconstruction in the Norwood procedure.

OBJECTIVES: After staged reconstruction for hypoplastic left heart syndrome, the neoaortic root tends to dilate, and the incidence of significant neoaortic valve insufficiency increases with time. This study aimed to evaluate the mid-term outcomes of the neoaortic root geometries and valve function after chimney reconstruction in the Norwood procedure. METHODS: Between 2013 and 2021, 20 consecutive patients who underwent chimney reconstruction during the Norwood procedure for hypoplastic left heart syndrome and its variants in our institution were enrolled. The actual diameters of the following points were measured, and Z-scores were calculated based on the normal aortic root geometries using the long axis view of echocardiography at the pre-Norwood stage and the lateral view of angiography at pre-Glenn, pre-Fontan, post-Fontan and follow-up (age 5-6 years) stages: neoaortic valve annulus; sinus of Valsalva; sinotubular junction; and ascending aorta just proximal to the anastomosis to the aortic arch. The degree of neoaortic valve regurgitation was evaluated by echocardiography at each stage. RESULTS: The median follow-up period was 3.9 years. Neoaortic roots after chimney reconstruction were spared from progressive dilation over time. With growth, the conical configuration of the neoaortic roots was preserved without geometrical distortion. The Z-scores of the annulus, sinus of Valsalva, sinotubular junction and ascending aorta ranged roughly from 4 to 6, 4 to 6, 2 to 4 and 0 to 2, respectively. All neoaortic valves at each stage had mild or no regurgitation. CONCLUSIONS: Chimney reconstruction prevented neoaortic root dilation and avoided significant neoaortic valve regurgitation in the mid-term. These neoaortic dimensions with smooth flow profiles in the neoaorta after chimney reconstruction may have contributed to the current results. Further studies are needed to clarify the long-term outcomes.

Fusion Imaging Objectively Demonstrates Improved Pancreas Visualization through Manipulation Techniques: A Prospective Interventional Study.

Objective Abdominal ultrasonography (AUS) is used to screen for abdominal diseases owing to its low cost, safety, and accessibility. However, the detection rate of pancreatic disease using AUS is unsatisfactory. We evaluated the visualization area of the pancreas and the efficacy of manipulation techniques for AUS with fusion imaging. Methods Magnetic resonance imaging (MRI) volume data were obtained from 20 healthy volunteers in supine and right lateral positions. The MRI volume data were transferred to an ultrasound machine equipped with a fusion imaging software program. We evaluated the visualization area of the pancreas before and after postural changes using AUS with fusion imaging and assessed the liquid-filled stomach method using 500 ml of de-aerated water in 10 randomly selected volunteers. Patients This study included 20 healthy volunteers (19 men and 1 woman) with a mean age of 33.0 (21-37.5) years old. Results Fusion imaging revealed that the visualization area of the entire pancreas using AUS was 55%, which significantly improved to 75% with a postural change and 90% when using the liquid-filled stomach method (p=0.043). Gastrointestinal gas is the main obstacle for visualization of the pancreas. Conclusion Fusion imaging objectively demonstrated that manipulation techniques can improve pancreatic visualization.

A new predictor of the optimal pulmonary artery reconstruction method during the arterial switch operation.

OBJECTIVES: The aim of this study was to more accurately predict the optimal pulmonary artery (PA) reconstruction procedure (Lecompte manoeuvre or original Jatene procedure) during the arterial switch operation, we focused on the horizontal sectioning (HS) angle between the left hilum PA and the great arteries using preoperative computed tomography imaging. METHODS: We defined the HS angle α (ß) as the angle between the tangential line from the posterior (anterior) wall of the left PA at the hilum to the left anterior (right posterior) surface of the main PA and the tangential line from the left surface of the ascending aorta to the left anterior (right posterior) surface of the main PA. We identified 14 consecutive patients diagnosed with transposition of the great arteries or transposition of the great artery-type double-outlet right ventricle who underwent preoperative computed tomography imaging. The original Jatene or Lecompte procedure was used for 9 (OJ group) and 5 (L group) patients. Relationships of the great arteries of the OJ and L groups were side by side in 8 and 2 patients, oblique in 1 and 1 patient and anteroposterior in 0 and 2 patients, respectively. RESULTS: In the OJ group, ß was greater than α in all patients. The median α/ß value was 0.618. In group L, α was greater than ß in all patients. The median α/ß was 1.307. Left PA stenosis caused by stretching was not observed in the L group. Coronary obstruction was not identified in the OJ group. Left PA stenosis behind the neo-ascending aorta was observed in 1 patient in the OJ group and required reoperation. CONCLUSIONS: The HS angle may be a useful predictor of optimal intraoperative PA reconstruction during arterial switch operation, especially for side-by-side or oblique relationships.

Multiple Pulmonary Artery Plasty With Tissue-Engineered Vascular Grafts.

In pediatric cardiovascular surgery, the autologous pericardium is useful for pulmonary artery augmentation. However, in some cases, the autologous pericardium may not be available for various reasons. Since 2014, we have developed tissue-engineered vascular grafts (TEVGs) and obtained good results. We report a successful case of multiple pulmonary artery plasty with TEVGs for pulmonary atresia/ventricular septal defect with major aortopulmonary collateral arteries. TEVGs are useful alternatives to autologous pericardium in pediatric cardiovascular operations that often require multistage procedures.

Physical Function and Low Back Pain in Leek Farmers: A Comparison with Non-Farmers.

Background: The purpose of this study was to investigate the low back pain (LBP) and physical function of young to middle aged farmers of leeks in western Tottori Prefecture. Methods: Fifteen farmers (55 years old or younger) cultivating leeks in western Tottori Prefecture were recruited as the subjects, and 14 non-farmers matching the age and sex of the subjects were recruited as the control group. A questionnaire survey was conducted to determine the presence or absence of LBP, smoking, and alcohol consumption. Physical functions were measured by anthropometry (body fat percentage and muscle mass), Finger-Floor distance (FFD), back muscle strength, and upper body bending, and lumbar muscle cross-sectional area (CSA) was evaluated by magnetic resonance imaging (MRI). Results: Weight, BMI, body fat percentage, upper body bending, back muscle strength, and L3/4 iliocostalis lumborum CSA, current LBP were significantly higher in the leek farmer group. One-way analysis of variance showed significant differences in upper body bending, and history of LBP. Conclusion: LBP was more common among leek farmers. The characteristics of leek farmers with LBP were history of LBP.

Surgical repair of a posterior left ventricular aneurysm in a 4-year-old boy.

Left ventricular aneurysms are rarely encountered in pediatric patients. A 4-year-old boy was diagnosed with severe mitral regurgitation and a posterior left ventricular aneurysm associated with a viral infection. The aneurysm was surgically resected and plicated longitudinally with a combination of an interrupted mattress and continuous over-and-over sutures with an outer felt reinforcement. The mitral regurgitation was reduced to a trivial degree postoperatively. The patient's postoperative recovery was good. He was discharged 31 days after surgery without cardiac dysfunction or lethal arrhythmia. Considering the location and spread of the aneurysm, an appropriate surgical procedure should be adopted for pediatric patients.

One-stage surgery for type A aortic dissection and iliac artery aneurysm rupture.

We present a patient with Stanford type A aortic dissection with malperfusion of the left kidney and lower extremity, and rupture of a common iliac artery aneurysm. After establishing lower extremity reperfusion using a percutaneous femorofemoral shunt in the emergency room, simultaneous open aortic arch repair and open abdominal aorta repair were performed. Our approach allowed concomitant repair of proximal dissection, limb ischemia, and iliac artery aneurysm rupture, all of which are critical predictors of mortality.

The effect of a valved small conduit on systemic ventricle-pulmonary artery shunt in the Norwood-type palliation.

OBJECTIVES: The aim of this study was to clarify the impact of valved systemic ventricle-pulmonary artery (SV-PA) shunt on outcomes after stage-1 Norwood-type palliation (NP) compared with the modified Blalock-Taussig shunt. METHODS: Consecutive patients who underwent NP between 2003 and 2019 were enrolled. SV-PA shunts using the expanded polytetrafluoroethylene valved conduit were implanted in 18 patients (valved SV-PA group), and another 18 patients underwent modified Blalock-Taussig shunt during NP (modified Blalock-Taussig shunt group). All valved conduits were made in our institution in advance. RESULTS: No differences in baseline characteristics were found between the groups, except for shunt size. During a median 2.9 (interquartile range 0.4-6.4, maximum 14.2) years of follow-up, 8 (22.2%) patients died across both groups. There were no statistically significant differences in early mortality (5.5% vs 11.1%, P = 0.55) and overall survival rates at 5 years (80.8% vs 71.4%, P = 0.48) in the valved SV-PA and modified Blalock-Taussig shunt groups. No statistically significant difference was observed in the frequency of interventions between the groups (31% vs 33%, P = 1.0). At the time of the bidirectional Glenn procedure, the systemic ventricular end-diastolic volume index was significantly lower (84 ± 24 vs 106 ± 31 ml/m2, P = 0.05) and the ejection fraction was significantly greater (62 ± 8% vs 55 ± 9%, P = 0.03) in the valved SV-PA group. There was no statistically significant difference in the pulmonary artery index (228 ± 85 vs 226 ± 60 mm2/m2, P = 0.92). CONCLUSIONS: A valved SV-PA shunt using an expanded polytetrafluoroethylene valved conduit was associated with preserved ventricular function after NP and did not impair pulmonary artery growth by controlling pulmonary regurgitation.

Evaluation of age-related changes in lumbar facet joints using T2 mapping.

BACKGROUND: The purpose in this study is to investigate the T2 value of lumbar facet joint (FJ) in subjects without lumbar spinal disorders, age from 20s to 70s, using T2 mapping, and to evaluate the correlation between age and T2 value. And also, we investigated the T2 value of lumbar intervertebral disc (IVD) in the same way as FJ, and evaluated the correlation between the T2 value of FJ and that of IVD. METHODS: We investigated 60 volunteers (30 male, 30 female), who were recruited from six age groups, 20s-70s (10 subjects in each decade; 5 male, 5 female). We measured the T2 values of FJ at the L4/5 level in axial image and those of IVD (nucleus pulposus; NP, anterior and posterior annulus fibrosus; AAF and PAF) at the L4/5 level in midline sagittal image. We investigated the correlation between age and T2 value of FJ, and the correlation between the T2 value of FJ and that of IVD. RESULTS: There was a strong positive correlation between age and T2 value of FJ (r = 0.717). Age and T2 values of IVD were negatively correlated (NP; r = -0.728, AAF; r = -0.696, PAF; r = -0.580). There was a negative correlation between T2 value of FJ and that of IVD (NP; r = -0.575, AAF; r = -0.617, PAF; r = -0.492). CONCLUSIONS: T2 value of FJ was significantly increased as age rose. Our results suggest that T2 mapping could detect the degenerative changes of FJ related to aging even in subjects without lumbar spinal disorders. The results of this study will be the reference data of FJ T2 value in order to evaluate the relationship between low back pain and FJ using T2 mapping.

Rescue from Stx2-Producing E. coli-Associated Encephalopathy by Intravenous Injection of Muse Cells in NOD-SCID Mice.

Shiga toxin-producing Escherichia coli (STEC) causes hemorrhagic colitis, hemolytic uremic syndrome, and acute encephalopathies that may lead to sudden death or severe neurologic sequelae. Current treatments, including immunoglobulin G (IgG) immunoadsorption, plasma exchange, steroid pulse therapy, and the monoclonal antibody eculizumab, have limited effects against the severe neurologic sequelae. Multilineage-differentiating stress-enduring (Muse) cells are endogenous reparative non-tumorigenic stem cells that naturally reside in the body and are currently under clinical trials for regenerative medicine. When administered intravenously, Musecells accumulate to the damaged tissue, where they exert anti-inflammatory, anti-apoptotic, anti-fibrotic, and immunomodulatory effects, and replace damaged cells by differentiating into tissue-constituent cells. Here, severely immunocompromised non-obese diabetic/severe combined immunodeficiency (NOD-SCID) mice orally inoculated with 9 × 109 colony-forming units of STEC O111 and treated 48 h later with intravenous injection of 5 × 104 Muse cells exhibited 100% survival and no severe after-effects of infection. Suppression of granulocyte-colony-stimulating factor (G-CSF) by RNAi abolished the beneficial effects of Muse cells, leading to a 40% death and significant body weight loss, suggesting the involvement of G-CSF in the beneficial effects of Muse cells in STEC-infected mice. Thus, intravenous administration of Muse cells could be a candidate therapeutic approach for preventing fatal encephalopathy after STEC infection.

Use of high b value diffusion-weighted magnetic resonance imaging in acute encephalopathy/encephalitis during childhood.

AIM: To determine the use of high b value diffusion-weighted imaging (DWI) in the diagnosis and assessment of acute febrile encephalopathy/encephalitis in childhood. SUBJECTS AND METHODS: We enrolled 22 children, for whom we examined DWI with b=1000s/mm2, DWI with b=3000s/mm2, and apparent diffusion coefficient (ADC) map with b=1000 during the acute phase of febrile encephalopathy/encephalitis. Clinical diagnoses included acute encephalopathy with biphasic seizures and late reduced diffusion (AESD; n=6), clinically mild encephalopathy/encephalitis with a reversible splenial lesion (MERS; n=6), and herpes simplex virus encephalitis (HSE; n=3), unclassified acute encephalopathy/acute encephalitis (n=2); acute encephalitis with refractory, repetitive partial seizures (AERRPS; n=1); other encephalopathy (n=1); infarction (n=1); head injury (n=1); or mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (n=1). The diagnostic quality of brain lesions was compared between b=1000 and b=3000 DWI images by visual inspection. In addition, we attempted a quantitative assessment using apparent diffusion coefficient (ADC) value and an index of signal intensity (SI) ratio, defined as the mean SI at the affected lesion divided by the mean SI at the pons. RESULTS: High intensity lesions were either visible only on b=3000 DWI (n=5; 2 AESD, 1 MERS, 1 HSE, and 1 unclassifiable encephalopathy) or more effectively identified on b=3000 DWI than on b=1000 DWI (n=17). The outcome of the former five subjects was favorable, without motor or intellectual sequelae. The mean SI ratio of b=3000 was significantly greater than that of b=1000 in AESD and MERS subgroups as well as in all 22 subjects. Mean ADC values were lower in the AESD and MERS than that in the HSE subgroups. CONCLUSION: We concluded that b=3000 DWI was superior to b=1000 DWI in detecting abnormal lesions in acute encephalopathy/encephalitis during childhood.

Carotid Plaque Evaluation Using Gemstone Spectral Imaging: Comparison with Magnetic Resonance Angiography.

BACKGROUND: The present study compared the applicability of computed tomography carotid plaque imaging using effective Z maps with gemstone spectral imaging (GSI) to that of magnetic resonance plaque imaging using 3-dimensional time-of-flight magnetic resonance angiography. METHODS: Stenosis was assessed in 18 carotid arteries of 14 patients, and the effective Z values of noncalcified carotid plaques were compared with the signal intensities of magnetic resonance angiography. RESULTS: It was found that the effective Z value of noncalcified carotid plaques was significantly lower for a group with high signal intensity than for a group with low signal intensity on magnetic resonance angiography (P <.001). The area under the receiver operating characteristic curve of effective Z values was .975, and the presumed cutoff effective Z value required to discriminate low and high intensity plaques on magnetic resonance angiography was 7.83. CONCLUSIONS: The effective Z value generated by GSI is a useful parameter to detect vulnerable carotid plaque materials.

R2* Map by IDEAL IQ for Acute Cerebral Infarction: Compared with Susceptibility Vessel Sign on T2*-Weighted Imaging.

BACKGROUND: To evaluate the detectability of arterial acute thrombus on R2* map by iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) IQ compared with T2*-weighted imaging (T2*WI). METHODS: Twenty-six patients with acute cerebral infarction who underwent R2* map and T2*WI were reviewed. We performed visual assessment of each sequence regarding the visibility of susceptibility effect reflecting acute thrombus and quantitative evaluation of the thrombus on R2* map. RESULTS: Both R2* map and T2*WI showed susceptibility effect reflecting acute thrombi at the occluded site of magnetic resonance angiography (MRA) in 9 patients. R2* map revealed positive while T2*WI showed equivocal findings in 3 patients due to the surrounding vessel signal intensity. Acute thrombus at distal internal carotid artery (ICA) on R2* map was more clearly detected than that on T2*WI without any apparent susceptibility artifact from the skull base in 4 patients. Most of cardiogenic embolic infarction (CEI) and artery-to-artery embolic infarction (A-to-A) demonstrated positive and most of atherothrombotic infarction (ATI) revealed negative findings on R2* map, although quantitative R2* values of thrombi did not show significant differences between CEI (136.6 /msec) and A-to-A (189.9 /msec) (P = 0.332). CONCLUSION: The detectability of acute thrombus on R2* map is comparable to that on T2*WI. Regarding thrombus at distal ICA, its detectability on R2* map is superior to that on T2*WI. R2* map provide additional information to distinguish between embolic and atherothrombotic infarctions.

A Novel Surgical Technique for Right-Sided Interrupted Aortic Arch by Interposition of a Pulmonary Autograft Tube.

Right-sided interrupted aortic arch (IAA) is a rare cardiac anomaly. In general, the right bronchus sits higher than the left bronchus, so aortic arch reconstruction with a direct anastomosis has a risk of tracheal and bronchial obstruction. This report describes the successful definitive repair of a right-sided IAA in a 2.5-kg neonate by aortic arch reconstruction with a pulmonary autograft tube (PA tube). Postoperative three-dimensional multidetector computed tomography showed the reconstructed aortic arch without airway obstruction or aortic stenosis. The use of a PA tube is a simple and useful technique for aortic arch reconstruction in patients with a high risk of tracheal andbronchial obstruction, such as right-sided IAA.

Smaller-Sized Expanded Polytetrafluoroethylene Conduits With a Fan-Shaped Valve and Bulging Sinuses for Right Ventricular Outflow Tract Reconstruction.

BACKGROUND: One of the critical factors limiting conduit longevity in right ventricular outflow tract (RVOT) reconstruction with homografts and xenografts is the small size of the conduit. The aim of our study was to assess the outcome of using smaller-sized expanded polytetrafluoroethylene (ePTFE) conduits with a fan-shaped valve and bulging sinuses for RVOT reconstruction. METHODS: This retrospective review examined 303 patients who underwent RVOT reconstruction with ePTFE conduits at 63 Japanese hospitals between 2003 and 2014. Inclusion criteria were a conduit size less than or equal to 16 mm and the use of operative treatment as the primary correction for underlying heart disease. Patients undergoing palliative procedures were excluded. RESULTS: Median follow-up was 1.7 years. Freedom from conduit replacement and freedom from conduit reintervention were 90.1% ± 4.8% and 77.2% ± 5.6%, respectively. The most common indication for conduit reintervention was pulmonary artery (PA) bifurcation stenosis (82%). Modeling z-scores as a dichotomous variable revealed that freedom from conduit reintervention for PA bifurcation stenosis was significantly decreased for conduits with a z-score greater than or equal to 1.4 compared with z-scores less than 1.4 (p = 0.036). There were 30 patients (9.9%) who experienced at least moderate conduit stenosis and 21 patients (6.9%) with at least moderate conduit insufficiency. Univariate Cox regression analysis showed that conduit size was a significant factor for conduit stenosis (p = 0.006). CONCLUSIONS: Excellent midterm outcomes were achieved with ePTFE valved conduits, even when using smaller sizes. Conduit z-scores around 1.4 were optimal for RVOT reconstruction in younger patients.

Vessel wall enhancement in the diagnosis and management of primary angiitis of the central nervous system in children.

We describe two cases of primary angiitis of the central nervous system in children (cPACNS) diagnosed by vessel wall contrast enhancement on magnetic resonance imaging (MRI). Both patients developed acute cerebral infarction after fever and malaise. In patient 1, a 7-month-old boy, MRI revealed extensive cerebral infarction in the right middle cerebral artery (MCA) area and stenosis at the M1 portion of the right MCA. Oral glucocorticoid therapy was initiated. Vessel wall enhancement was ameliorated 3months after onset, and stenosis was mostly restored. Patient 2, a 5-year-old boy, suffered from cerebral infarction in the left MCA area, and stenosis was identified in the left internal carotid artery, left MCA, and left posterior cerebral artery. Although vessel wall enhancement was reduced after glucocorticoid therapy, vessel wall enhancement of left MCA re-emerged, accompanied by increased erythrocyte sedimentation rate (ESR) and, decreased cerebral blood flow (CBF) in the affected hemisphere. Intravenous methylprednisolone therapy followed by oral glucocorticoid and mycophenolate mofetil resulted in resolution of these findings. Vessel wall enhancement is a promising finding in the diagnosis of cPACNS. Disease flares occur rarely in medium-to-large vessel cPACNS during dose tapering. Vessel wall enhancement, ESR, and CBF may be useful for the assessment of the activity of angiitis.

[A Case Report of Early Gastric Cancer with Submucosal Heterotopic Gastric Glands].

We reported a case of early gastric cancer with submucosal heterotopic gastric glands.A 62-year-old woman presented with poor appetite, weight loss, and epigastric pain.Endoscopy examination identified giant gastric folds and a gastric ulcer on the posterior wall of the upper-middle stomach.Biopsy specimen analysis showed adenocarcinoma.We preoperatively diagnosed the lesion as type II c-like advanced cancer and performed a total gastrectomy.Pathologically, the lesion was diagnosed as gastric cancer(non-solid type poorly differentiated adenocarcinoma)located in the mucosal layer and accompanied by submucosal heterotopic gastric glands.Submucosal gastric gland heterotopia is a relatively rare disease, and it is difficult to diagnose the glands before surgery is performed.However, endoscopic ultrasonography helps to demonstrate diffuse cystic lesion preoperatively.It is often associated with multiple gastric cancers.Therefore, we must diagnose and treat the disease with great care.