[Right Atrium Thrombus Due to Cardiac Amyloidosis;Report of a Case].

A 51-year-old man complaining of exertional dyspnea and syncope was admitted to our hospital. Computed tomography(CT) and transesophageal echocardiography demonstrated a mobile tumor-like lesion in the right atrium. Surgical resection was performed under cardioplegic arrest, which revealed an organized thrombus. Pathological examination revealed amyloid deposition in the myocardium, and bone marrow biopsy revealed CD138 (+) stem cells. Therefore, the patient was diagnosed with amyloid light-chain (AL) amyloidosis associated with multiple myeloma. Although he required percutaneous cardiopulmonary support for postoperative right heart failure for 3 days, he recovered well and was discharged from the hospital on day 44, in a good condition. He was treated with bortezomib for multiple myeloma after surgery. Thus, despite the maintenance of sinus rhythm, intra-cardiac thrombus could be formed with amyloidosis.

[Idiopathic Pulmonary Artery Aneurysm].

Pulmonary artery aneurysm (PAA) is usually associated with congenital heart disease, pulmonary artery hypertension, and connective tissue abnormalities, but idiopathic PAA is a rare clinical entity. We experienced a surgical case of idiopathic PAA measuring 60 mm in diameter. A 72-year-old man had been admitted to a nearby hospital 5 years before because of an abnormal shadow on chest X-ray, and was diagnosed with an idiopathic PAA measuring 37 mm in diameter. The PAA gradually expanded during follow-up and surgery was scheduled. Aneurysmal resection and reconstruction with a 24 mm expanded polytetrafluoroethylene graft were performed. The postoperative course was uneventful and the patient was discharged on the 11th postoperative day.

[Two-stage Surgery for Uterine Intravenous Leiomyomatosis with Right Ventricular Extension;Report of a Case].

Intravenous leiomyomatosis is a rare neoplastic condition characterized by the benign intravascular proliferation of smooth muscle cells originating from either the uterine venous wall or a uterine leiomyoma. In the present report, we describe the case of a 36-year-old woman, who was referred to our institution due to abdominal pain. Computed tomography indicated the presence of a giant intravenous leiomyoma originating from the uterus and extending to the right ventricle with complex pathways. The patient was successfully treated by tumor resection under circulatory arrest in two-stage operations in conjunction with gonadotrophin-releasing hormone agonists therapy. She continued to recover and did not exhibit any recurrence at the 8-month follow-up.

[Rupture of an Aneurysm of the Right Sinus of Valsalva Into the Pericardium;Report of a Case].

A sinus of Valsalva aneurysm is an uncommon cardiac anomaly. The aneurysm usually ruptures into the cardiac cavity, and rupture into the pericardial cavity is unusual. A 69-year-old man was admitted to our hospital after collapse due to cardiac tamponade. Computed tomography revealed a ruptured right sinus of Valsalva aneurysm (5 cm) with massive pericardial effusion. The right coronary artery arose from the aneurysm. Severe aortic regurgitation due to the lack of coaptation of the valves was detected by echocardiography. Emergency patch closure of the aneurysm orifice, aortic valve replacement, and coronary artery bypass grafting to the right coronary artery were performed. The postoperative course was uneventful and the patient was discharged on postoperative day 28 in good health.

[Coronary Artery Perforation Secondary to Primary Percutaneous Coronary Intervention;Report of a Case].

Stent perforation of a coronary artery during percutaneous coronary intervention (PCI) is a rare but life-threatening complication. A 70-year-old man was admitted to our hospital for management of acute coronary syndrome. PCI was attempted for the left circumflex artery(LCX);however, catheterization was complicated by perforation of the LCX by the stent. He developed cardiac tamponade and was resuscitated using percutaneous cardiopulmonary support. Emergency surgery( ligation of the LCX and aorto-coronary bypass grafting for the distal LCX) was performed. His postoperative course was uneventful, and the patient was discharged on the 20th postoperative day. Collaboration between cardiologists and surgeons is essential to salvage such a critical patient.

[Prophylactic Effectiveness of Vacuum-assisted Closure for High-risk Patients Undergoing Cardiovascular Surgery through Median Sternotomy].

Vacuum-assisted closure(VAC) therapy is mainly used for tissue defects. VAC therapy can remove exudate that could impair the healing process. We applied VAC therapy in patients considered at high risk of surgical site infection who underwent cardiovascular surgery via standard median sternotomy. Risk factors included advanced heart failure, obesity, diabetes mellitus, steroid administration, immunosuppressant administration, and chronic renal failure, etc. VAC therapy was used in 134 patients. Only 3 of these patients (2.2%) developed surgical site infection caused by Staphylococcus epidermidis;2 patients fully recovered after prolonged VAC therapy for 2 weeks, and the other required an additional sternal fixation after the sternal wires were removed for wound infection control. No patient developed infective mediastinitis. Prophylactic VAC therapy can reduce postoperative wound infection in high risk patients undergoing open heart surgery via full sternotomy.

[Surgical Treatment of Prosthetic Valve Endocarditis].

Between 2003 and 2014, at Jichi Medical University Hospital, 11 patients with prosthetic valve endocarditis (PVE) underwent re-operation. There was 1 in-hospital death and 2 late deaths. The cause of death was cirrhosis, heart failure and sepsis, respectively. Emergency surgery, previous double valve replacement (DVR) and Staphylococcus infection were common risk factors for all 3 cases. Two cases of patients that survived who underwent mitral valve replacement (MVR) and DVR for PVE after DVR were treated with multiple antibiotic courses for bacteremia associated with hemodialysis and colon cancer. One patient who underwent DVR after mitral valve plasty which was complicated with cerebral hemorrhage, had survived and was discharged. Of the aortic PVE patients, 2 cases of aortic valve replacement (AVR) using a mechanical valve, 1 case of aortic root replacement (ARR) using a mechanical valve, and 1 ARR using the homograft, were considered cured and never relapsed. A patient with aortic PVE, who underwent AVR after cesarean section for heart failure in birth period, has received ARR twice with the mechanical valve for recurrent pseudo-aneurysm of the left ventricular outflow tract. Since hemodialysis and colon cancer is a risk factor for recurrent PVE, it is necessary to consider the long-term administration of antibiotics after surgery.

Morphological Changes in Endothelial Cell Organelles in a No-Touch Saphenous Vein Graft.

INTRODUCTION: Improved long-term patency of the no-touch (NT) saphenous vein graft has been reported to result from the preservation of a healthy vascular microstructure, especially endothelial cells. However, the precise morphology of endothelial cells and their organelles in NT saphenous vein graft has not been fully investigated. In this study, we assessed the ultrastructure of preserved endothelial cells in saphenous vein graft using transmission electron microscopy. METHODS: Intact control (IC) vein, NT saphenous vein graft, and conventional (CT) saphenous vein graft were harvested from a patient. After observation by light microscopy, the nuclei and mitochondria in the preserved endothelial cells were compared among IC, NT, and CT using transmission electron microscopy, and the endothelial organelles were assessed quantitatively. RESULTS: Light microscopy showed that the preservation of endothelial cells was comparable in IC, NT, and CT. Subsequent transmission electron microscopy observation showed that the nuclei in preserved endothelial cells appeared more swollen in CT than that in NT. Quantitative analysis revealed that nuclear size and circularity of preserved endothelial cells in NT and IC were similar, but those in CT were larger and higher, respectively, than those in IC and NT. In addition, the mitochondrial size in preserved endothelial cells in CT was larger than that in IC and NT. CONCLUSION: Necrotic changes in endothelial organelles characterized by swelling of nuclei and mitochondria were prominent in CT saphenous vein graft. The normally maintained ultrastructure of preserved endothelial cells in NT saphenous vein graft could contribute to long-term patency.

Artificial endocrine pancreas with a closed-loop system effectively suppresses the accelerated hyperglycemic status after reperfusion during aortic surgery.

OBJECTIVES: To control intraoperative hyperglycemia in patients who underwent aortic surgery using STG-55® artificial endocrine pancreas and clarify the effectiveness of this device. METHODS: Blood glucose control using the STG-55® was performed in 18 patients (15 men and 3 women; age, 66 ± 10 years) who required hypothermic circulatory arrest (STG-55® group). Seventeen patients (10 men and 7 women; age, 71 ± 8 years) whose blood glucose was controlled using the conventional method were included in the control group. Glucose concentration was controlled with the aim of maintaining it at 150 mg/dl. RESULTS: In both groups, the blood glucose concentrations did not significantly change during the interruption of systemic perfusion; however, a sharp increase was noted immediately after reperfusion. Although the hyperglycemic status persisted after reperfusion in the control group, it was effectively suppressed in the STG-55® group (STG® vs. control group at 50 min after reperfusion: 180 ± 35 vs. 212 ± 47 mg/dl, p = 0.026) and blood glucose concentration reached the target value of 150 mg/dl at 100 min after reperfusion (STG® vs. control group: 153 ± 29 vs. 215 ± 43 mg/dl, p = 0.0008). The total administered insulin dose was 175 ± 81 U and 5 ± 3 U in the STG® and control groups, respectively (p < 0.0001). CONCLUSIONS: To treat the accelerated hyperglycemic status in aortic surgery requiring circulatory arrest, strict glycemic control using an artificial endocrine pancreas might be beneficial.

Acute aortic occlusion after microendoscopic laminectomy in a patient with lumbar spinal stenosis: A case report.

RATIONALE: Acute aortic occlusion is an uncommon disease with a high morbidity and high mortality. Clinical symptoms typically include acute lower limb pain, acute paralysis, and absent pulses. We report a very rare case of acute aortic occlusion causing complete paralysis of bilateral lower limbs following microendoscopic laminectomy. PATIENT CONCERNS: A 64-year-old man with hypertension, hyperlipidemia, diabetes, and atrial fibrillation underwent microendoscopic laminectomy for lumbar spinal stenosis. After the operation, intermittent claudication improved significantly without neurological deficit. However, 7 days later, he developed complete paralysis of the bilateral lower limbs, extreme pain of the bilateral lower limbs, and mottling of the left extremity. DIAGNOSIS: An emergency magnetic resonance imaging examination revealed no epidural hematoma behind the spinal cord, proscribing spinal cord compression. Computed tomography revealed occlusion of the infrarenal abdominal aorta. Blood tests revealed high values of total plasminogen activator inhibitor-1 before surgery. INTERVENTIONS: The acute aortic occlusion was verified and underwent thrombectomy and right axillary-bifemoral bypass. OUTCOMES: Following the revascularization, the neurological deficit of the lower limbs improved. On follow-up after 1 year, the muscle strength of the bilateral lower limbs had returned to normal. LESSONS: This case presentation highlights the necessity of early diagnosis and early revascularization. Moreover, a preoperative high value of plasminogen activator inhibitor-1 may indicate vascular complications including Acute Aortic Occlusion.

A case of immunoglobulin G4-related aortic diseases.

A 65-year-old man had histories of retroperitoneal fibrosis, membranous nephropathy, and acute coronary syndrome. Chest computed tomography showed an enlarged ascending aorta and type B aortic dissection, and he underwent ascending aorta and arch replacement. A pathological examination of the resected aorta showed immunoglobulin G4-positive plasma cell infiltration.

Morphological Changes in Endothelial Cell Organelles in a No-Touch Saphenous Vein Graft

ABSTRACT Introduction: Improved long-term patency of the no-touch (NT) saphenous vein graft has been reported to result from the preservation of a healthy vascular microstructure, especially endothelial cells. However, the precise morphology of endothelial cells and their organelles in NT saphenous vein graft has not been fully investigated. In this study, we assessed the ultrastructure of preserved endothelial cells in saphenous vein graft using transmission electron microscopy. Methods: Intact control (IC) vein, NT saphenous vein graft, and conventional (CT) saphenous vein graft were harvested from a patient. After observation by light microscopy, the nuclei and mitochondria in the preserved endothelial cells were compared among IC, NT, and CT using transmission electron microscopy, and the endothelial organelles were assessed quantitatively. Results: Light microscopy showed that the preservation of endothelial cells was comparable in IC, NT, and CT. Subsequent transmission electron microscopy observation showed that the nuclei in preserved endothelial cells appeared more swollen in CT than that in NT. Quantitative analysis revealed that nuclear size and circularity of preserved endothelial cells in NT and IC were similar, but those in CT were larger and higher, respectively, than those in IC and NT. In addition, the mitochondrial size in preserved endothelial cells in CT was larger than that in IC and NT. Conclusion: Necrotic changes in endothelial organelles characterized by swelling of nuclei and mitochondria were prominent in CT saphenous vein graft. The normally maintained ultrastructure of preserved endothelial cells in NT saphenous vein graft could contribute to long-term patency.

Catastrophic myocardial ischemia resulting from a left coronary artery anomaly with an origin in the right sinus of Valsalva.

A congenital left coronary artery anomaly originating from the right aortic sinus is a rare congenital defect associated with the risk of sudden death in young individuals. In most cases, the proximal portion of the anomalous left coronary artery exists between the ascending aorta and pulmonary trunk, and it has an intramural aortic course; this could critically impair the left coronary flow owing to compression of the anomalous left main trunk between the great vessels during exercise. Herein, we report a 14-year-old boy who experienced cardiac collapse due to an acute myocardial infarction after long-distance running. After resuscitation using percutaneous cardiopulmonary support, computed tomography and coronary angiography revealed an anomalous origin of the left main coronary artery in the right sinus of Valsalva and a proximal course between the aorta and pulmonary trunk. The patient was successfully treated using an unroofing procedure of the intramural left coronary artery.

Delayed visceral ischemia induced by type B aortic dissection.

Case: A 56-year-old man presented with a sudden severe abdominal pain 13 days after the onset of type B acute aortic dissection. Chest computed tomography revealed type B aortic dissection, and the true lumen was narrowed by the expanding false lumen. Blood flow through the celiac trunk, superior mesenteric artery, and left renal artery was reduced. Blood flow through the distal abdominal aorta and bilateral femoral arteries was clearly recognized. Laboratory findings such as transaminases were rapidly worsening. Outcome: The patient underwent emergency fenestration of the abdominal aorta and recovered without organ failure. Conclusions: Rapidly worsening laboratory findings led us to emergency operation with successful results. Serial monitoring of laboratory findings is the key for adequate timing of operation.

Fifteen-year experience with the Bicarbon heart valve prosthesis in a single center.

BACKGROUND: The purpose of this study was to evaluate retrospectively the clinical performance of the Bicarbon valve (Sorin Biomedica Cardio, Saluggia, Italy) implanted at our center in Japan. METHODS: Between January 1997 and December 2011, 415 patients in our institution were implanted with the Bicarbon valve. Nine of these recipients were excluded from the study because they had already undergone valve implantation and received a Bicarbon valve in a different position. The remaining patients were analyzed for evaluation of the postoperative clinical outcomes. Of the 406 patients (mean age 60.2 ± 11.7 years), 179 underwent aortic valve replacement (AVR), 149 mitral valve replacement (MVR), and 78 both aortic and mitral valve replacement (DVR). RESULTS: There were 10 early deaths (2.5 %: 4 in the AVR group and 6 in the MVR group). Three hundred eighty-nine patients were followed up (95.8 % completeness of follow-up) with a mean follow-up of 6.6 ± 4.2 years overall (AVR 6.8 ± 4.2, MVR, 6.7 ± 4.4, and DVR 5.7 ± 3.4 years) and a cumulative follow-up of 2661 patient-years (1214, 1001, and 446 patient-years for AVR, MVR, and DVR, respectively). Ninety-nine patients died (3.7 % per patient-year: 22 valve-related and 77 valve-unrelated deaths). Survival at 10 years was 74.1 ± 4.0 % in the AVR group, 73.7 ± 4.2 % in the MVR group, and 61.0 ± 7.9 % in the DVR group. The linearized incidence of thromboembolic complications, bleeding complications, prosthetic valve endocarditis, paravalvular leaks, and sudden death in all patients was 0.5 %, 0.5 %, 0.2 %, 0.2 %, and 0.4 % per patient-year, respectively. The incidence of valve-related complications and reoperation was 1.6 % and 0.4 %, respectively. No other valve-related complications were observed. CONCLUSIONS: The Bicarbon prosthetic heart valve has shown excellent clinical results and is associated with a low incidence of valve-related complications.

Experimental diabetes accelerates accumulation of fluorescent pigments in rat trigeminal neurons.

The purpose of this study was to investigate autofluorescent pigment granules (lipofuscin, ceroid) in the trigeminal neurons (TN) during aging and streptozotocin-induced diabetes. Four young adult male rats were injected with streptozotocin (STZ; 50 mg/kg) to produce diabetes (DM), for comparison with four young uninjected control rats and four aged rats (90 weeks old). Eight weeks after STZ injection, all rats were fixed with 4% paraformaldehyde, and paraffin sections of TN were prepared and observed by fluorescence microscopy. We found the number of neurons with autofluorescent pigments had increased to 30.38% of the total in DM compared to 8.98% in the control group, and 25.36% in the aged rats. The area of autofluorescence within those neurons was 16.84% in aged rats, 13.02% in DM and 4.45% in the controls. Thus, DM caused accelerated accumulation of fluorescent granules in trigeminal neurons, and this change may show that premature aging contributes to neuronal functional decline and morphological change.

Inhibitory effects of incadronate on the progression of rat experimental periodontitis by porphyromonas gingivalis infection.

BACKGROUND: Incadronate (YM175, disodium cycloheptylaminomethylenediphosphonate monohydrate), a bisphosphonate, has been suggested to prevent the bone resorption associated with periodontitis by inhibiting osteoclast activity. The purpose of this study was to investigate the effect of incadronate in preventing periodontal destruction in rats with Porphyromonas gingivalis-induced periodontitis. METHODS: Periodontitis was induced in 35 Wister rats by inoculating P. gingivalis into the oral cavity and feeding the rats a soft diet for 4 weeks. Incadronate or placebo was administered to the oral cavity of the rats 2 days per week for 2, 4, or 8 weeks. RESULTS: P. gingivalis infection resulted in destruction of the periodontal ligament, reduced bone density, and caused inflammatory cell migration. Radiographic, morphometric, and histological results showed that incadronate had the ability to increase the bone mineral density (quantum level score; cortex 518.9 [placebo 612.8]; sponge 579.8 [placebo 672.0]) and to prevent periodontal ligament destruction (width 0.16 mm [placebo 0.20 mm]; area 0.36 mm2 [placebo 0.54 mm2]) after 8 weeks' administration. Furthermore, the polymorphonuclear leukocyte (PMN) infiltration in gingival tissue was significantly decreased. CONCLUSION: These results showed that incadronate inhibits bone resorption and PMN migration in P. gingivalis-induced periodontitis.

A worn Björk-Shiley prosthetic valve without valve dysfunction observed during ascending aortic replacement.

KEY CLINICAL MESSAGE: The implanted first-generation Björk-Shiley valve in our patient was functioning well before aortic surgery, but we replaced the valve because we confirmed disc erosion 39 years after implantation during the surgery. We judged that the implanted valve was no longer capable of maintaining the patient's life.

The influence of ß-tricalcium phosphate blocks containing extracellular matrix on osteogenic differentiation of rat bone marrow stromal cells.

BACKGROUND: The aim of the present study is to assess the osteogenic differentiation of rat bone marrow stromal cells (RBMCs) in ß-tricalcium phosphate (ß-TCP) blocks containing extracellular matrix (ECM) produced by human alveolar bone periosteal cells (HABPCs). METHODS: HABPCs were cultured in ß-TCP blocks for 1 week (group 1) and 2 weeks (group 2). ß-TCP blocks containing ECM were then created by drying the blocks for 3 days. RBMCs were cultured in the blocks containing ECM for 2 weeks. In the control group, RBMCs were cultured in ß-TCP blocks alone for 2 weeks. HABPCs and RBMCs in the blocks were examined by histologic and immunohistochemical analyses. RESULTS: Histology revealed a significantly higher number of HABPCs in the group 2 blocks than in the group 1 blocks. HABPCs produced several bone matrix proteins in the blocks, and these positive reactions in group 2 were significantly higher than in group 1. Both groups showed a significantly higher number of RBMCs than the control group. RBMCs produced osteopontin and osteocalcin in the blocks, and these positive reactions were significantly higher in both test groups than in the control group. The number of osteocalcin-positive reactions was higher in group 2 than in group 1. CONCLUSION: Osteogenic differentiation of RBMCs cultured for 2 weeks in ß-TCP blocks containing ECM was significantly higher than that of cells cultured for 1 week or without ECM.