[Infectious Thoracic Aortic Aneurysm and Purulent Pericarditis due to Staphylococcus aureus:Report of a Case].

The objective of this case report is to highlight a rare case of infectious thoracic aortic aneurysm and purulent pericarditis simultaneously in a 56-year-old woman. The patient complained of left anterior chest pain and contrast computed tomography (CT) revealed infectious thoracic aortic aneurysm and purulent pericarditis accompanied by massive pericardial effusion. She underwent a pericardial drainage immediately, and antibiotic treatment was initiated. Methicillin-sensitive Staphylococcus aureus was detected in blood and pericardial fluid cultures. On day eight of hospitalization, contrast CT scan showed enlargement of the aortic aneurysm. Therefore, total arch replacement was performed on day 10 using rifampicin-soaked graft. After surgery, antibiotic treatment was continued, till inflammatory markers became negative. She was discharged on day 66 without developing anastomotic pseudoaneurysms nor constrictive pericarditis.

[Stanford Type A Acute Aortic Dissection with Acute Myocardial Infarction due to Compression of Left Main Coronary Artery:Report of a Case].

A 58-year-old man was admitted to our institution with sudden onset of hypotension and acute ischemia of left lower extremity. Electrocardiography showed ST segment elevation in leads V1~V6 and a transthoracic echocardiogram revealed antero-septal wall hypokinesis. He was given a diagnosis of acute myocardial infarction caused by left main coronary artery compression due to acute aortic dissection by enhanced computed tomography. We implanted a stent in the left main coronary artery and performed right external iliac-left femoral arterial bypass under general anesthesia. We performed a conventional total arch replacement and frozen elephant trunk and mitral valve repair at day 16. His postoperative course was good. Implantation of a left main trunk stent is an effective strategy for Stanford type A acute aortic dissection with left main coronary arterial occlusion before surgical repair.

[Surgical Outcomes of Aortic Root Repair in Type A Acute Aortic Dissection].

We carried out a retrospective evaluation of the early and long-term outcomes of aortic root reconstruction for type A acute aortic dissection. Between January 2001 and March 2015, a total of 21 patients underwent aortic root reconstruction. Bentall operation was performed in 9 patients( B group) and Patch plasty of sinus of Valsalva patients was performed in 12 patients (V group). There were 3 in-hospital deaths due in the B group and 1 death due in the V group. Overall survival in the V group was 72.9% and was not significantly different from survival in the B group(66.7%). In conclusion, our study demonstrated good early and long-term outcomes for patch plasty of sinus of Valsalva for type A acute aortic dissection. There was no postoperative patch-related complication in the V group. Thus, a patch plasty of sinus of Valsalva for type A acute aortic issection may be acceptable.

[Early and Late Outcomes of Valve Surgery in Active Infective Endocarditis Patients with Cerebral Complications].

We carried out a retrospective evaluation of the early and late outcomes of valve surgery for acute endocarditis patients with cerebrovascular disease. Between January 2002 and August 2014, a total of 17 patients (early group, n=10;delayed group, n=7) underwent valve surgery with or without an additional procedure. Craniotomy was performed in 1 patient in the early group and 2 patients in the delayed group before valve surgery. There was 1 in-hospital death due to acute respiratory distress syndrome in the early group and 1 death due to intestinal bleeding in the delayed group. Postoperative deterioration was observed in 1 in the delayed group. Overall survival in the early group was 90% and was not significantly different from survival in the delayed group (86%). In conclusion, our study demonstrated good early and mid-term outcomes for valve surgery in active endocarditis patients with cerebrovascular disease. There was no postoperative deterioration in the early group. Thus, an early operation for these patients may be acceptable.

Descending aorta-external iliac artery bypass for middle aortic syndrome.

We encountered a surgical case of middle aortic syndrome (MAS) in a 56-year-old man who had resistant hypertension. Computed tomography showed severe stenosis of the abdominal aorta from below the superior mesenteric artery to above the inferior mesenteric artery. Although bilateral renal artery stenosis was confirmed, renal function was within normal limits. A 10-mm vascular prosthetic graft was used to perform a descending aorta to left external iliac artery bypass. His hypertension was well controlled without medication. This extra-anatomic bypass may be a simple and useful approach for treating MAS if it is not necessary to reconstruct the renal artery or visceral artery.

Erythropoietin, but not asialoerythropoietin or carbamyl-erythropoietin, attenuates monocrotaline-induced pulmonary hypertension in rats.

Erythropoietin (EPO) has long been utilized for the treatment of renal anemia. The erythropoietin receptor (EPOR) is also expressed in the cardiovascular and central nervous systems in addition to an erythroid lineage, to provide an organoprotective role against several types of cellular stress. Pulmonary hypertension (PH) is a poor prognostic disease caused by primary and secondary pulmonary vascular injury. We observed the effects of EPO derivatives on monocrotaline-induced PH in rats on the supposition that EPO may protect small arteries from injury. Asialoerythropoietin (AEPO) lacks sialic acids in the termini of carbohydrate chains that results in rapid clearance from blood. Carbamyl-erythropoietin (CEPO) interacts with EPOR/ßc heterodimers, but not with EPOR homodimers expressed in erythroid cells. Monocrotaline-injected rats were treated with continuous intravenous injection of 2500 ng/kg/day of EPO, AEPO, or CEPO for 21 days, and lung histology, cardiac function, and mRNA expression in the lungs were examined. Wall thickening of small arteries in the lungs and PH were improved by administration of EPO, but not by its non-hematopoietic derivatives, AEPO, or CEPO. Erythropoietin administration increased mRNA expression of the anti-apoptotic molecule, Bcl-xL, and maintained expression of the CD31 antigen. We conclude that lungs may express EPOR homoreceptors, but not heteroreceptors. Adequate serum erythropoietin levels may be essential for pulmonary protective effects.

A Case Series of Secondary Aortoenteric Fistula after Open Aortic Aneurysm Repair: Timing and Technique of Surgery.

Secondary aortoenteric fistula (sAEF) is a rare but serious complication after open aortic aneurysm repair (OAR). Although there is no consensus on the treatment strategy for sAEF, acute management of bleeding and infection control greatly affect the outcome. We report five cases of sAEF following OAR from 2016 to 2021. One patient died of sepsis following graft infection, whereas the others had relatively good outcomes. No recurrence of infection or fistula has been observed over an average follow-up period of 29.8 months. Timely management of bleeding and infection with surgical intervention resulted in favorable outcomes in our patients.

Aortic Angiosarcoma in Association with Endovascular Aneurysm Repair: Case Report and Review of the Literature.

BACKGROUND Primary aortic sarcoma often poses diagnostic challenges for pathologists and clinicians because of a very low incidence and controversy over nomenclature and definition. We report a case of aortic angiosarcoma in association with a graft. We also conducted a clinicopathological review of cases of primary aortic sarcomas associated with implanted grafts. CASE REPORT The patient was an 82-year-old woman. She underwent thoracic endovascular aneurysm repair (TEVAR) at age 78 because of an aneurysm in the descending aorta. Approximately 4 years after the TEVAR, computed tomography revealed a type II endoleak and expansion of the aneurysm. Her c-reactive protein level rose to 34 mg/dL, and Ga scintigraphy showed 67Ga accumulation at the aneurysm. She had fever up to 39°C, and a stent graft infection was suspected. Despite administration of antibiotics, her condition deteriorated, and she died. Postmortem examination identified epithelioid aortic angiosarcoma at the aorta with aneurysm repair and the graft, and the aortic angiosarcoma invaded the left lower lobe of the lung. CONCLUSIONS Our clinicopathological review revealed that the proper clinical diagnosis was very difficult owing to confusion of aortic sarcoma after the implantation with the infected graft, atypical endoleak, or pseudoaneurysm. The histological diagnosis was ambiguous because immunohistochemical and genetic studies were not adequately conducted. Overall prognosis of aortic sarcoma is poor as most patients die within a year, with no effective treatments. It is hoped that recent projects for genomic medicine will provide useful insights about the diagnosis and treatment of these cancers.

Lipocalin-2/neutrophil gelatinase-B associated lipocalin is strongly induced in hearts of rats with autoimmune myocarditis and in human myocarditis.

BACKGROUND: Lipocalin-2/neutrophil gelatinase-B associated lipocalin (Lcn2/NGAL) is involved in the transport of iron and seems to play an important role in inflammation. A recent study has reported that it is also expressed in the failing heart and may be a biomarker not only for renal failure but also for heart failure. Because Lcn2/NGAL is thought to be induced by interleukin-1, it might be strongly induced in the presence of myocarditis. METHODS AND RESULTS: This study investigated the expression of Lcn2/NGAL in rat experimental autoimmune myocarditis (EAM) and in human myocarditis. In EAM hearts, the expression of Lcn2/NGAL was markedly increased (>100-fold at an early stage), and in human myocarditis it was also highly expressed compared with non-inflammatory failing hearts. Lcn2/NGAL expressing cells in hearts with EAM and human myocarditis were identified as cardiomyocytes, vascular wall cells, fibroblasts and neutrophils. Lcn2/NGAL in EAM rats was also expressed in the liver. Plasma Lcn2/NGAL levels abruptly increased at an early stage of EAM, and high levels were initially sustained during the inflammatory stage, then decreased with recovery. In contrast, levels of B-type natriuretic peptide increased only slowly as the disease progressed. CONCLUSIONS: Cardiomyocytes, vascular wall cells and fibroblasts in myocarditis strongly express Lcn2/NGAL via proinflammatory cytokines.

Major factors of homologous blood transfusion in valvular heart operation with intraoperative autologous blood predonation in cases with difficulty in preoperative predonation.

Intraoperative autologous blood predonation is reported to be useful for the prevention of homologous blood transfusion in cardiac operations, especially in on-pump coronary artery bypass grafting (CABG). However, CABG is now performed more often off-pump than on-pump. We analyzed the major factors of homologous blood transfusion in 25 consecutive cases of valvular heart operation with intraoperative autologous blood predonation except those with preoperative autologous blood donation. Homologous blood was not transfused in 18 cases, but was in 7 cases only after cardiopulmonary bypass (CPB). The homologous transfusion was not correlated with body weight, CPB dilution or duration, or preoperative hematocrit level, but was found to correlate with age (r2=0.289, p=0.0413), bleeding output (r2=0.197, p=0.0485), and predonation blood volume (r2=0.436, p=0.0152). In conclusion, suitable intraoperative predonation may reduce the necessity for homologous blood transfusion in valvular heart operations.

Imatinib mesilate inhibits neointimal hyperplasia via growth inhibition of vascular smooth muscle cells in a rat model of balloon injury.

Restenosis is a major problem in percutaneous catheter intervention (PCI) for coronary artery stenosis in patients with acute myocardial infarction. Coronary restenosis arises from intimal hyperplasia, i.e., hyperplasia of the vascular smooth muscle cells (SMCs) caused by endothelial cell (EC) damage due to PCI. Drug eluting stent (DES), a novel stent coated with a cell-growth inhibitor, such as rapamycin, has been utilized to block SMC proliferation, but DES also blocks EC repair and thus requires the administration of anti-platelets for a long time to prevent thrombus formation after PCI. Moreover, insufficient prevention of platelet aggregation sometimes induces restenosis after PCI. One of the signal transduction inhibitors, imatinib mesilate, blocks tyrosine kinase activity of platelet-derived growth factor receptor (PDGFR), and therefore it may block the development of neointima through growth inhibition of SMCs without the obstructive effect on EC-repair. We therefore studied the effects of imatinib on neointimal hyperplasia in a balloon injury model of rat carotid arteries. Rats were orally administered with imatinib for 14 days after balloon injury, and sacrificed to analyze the neointimal formation. Intimal hyperplasia was inhibited by imatinib in a dose-dependent manner. Therefore imatinib presumably obstructed the growth of SMCs via interception on growth-signaling of PDGFR. The administration of imatinib after coronary stenting or the use of an imatinib-eluting stent may further reduce the risk of restenosis in patients.

[Long-term results after recurrence of completely resected primary lung cancer].

The recurrence rate of complete surgical resection and the long-term results following recurrence have rarely been reported. Whether patients with recurrence could be cured is still unknown. Patients who underwent complete surgical resection for lung cancer from 1981 to 1999 (n=945) and were followed-up for more than 5 years were retrospectively reviewed. Recurrent diseases were treated by chemotherapy and/or radiotherapy when surgical treatment was not indicated. Postoperative 5-year survival in 585 patients (62%) without recurrence and in 360 patients (38%) with recurrent diseases were 84 and 27%, respectively. The recurrence rates of stage I patients (n=164), stage II (n=55), stage III (n=127) and stage IV (n=13) were 26, 52, 68 and 93%, respectively. The 5-year survival rates of these patients were 36, 23, 19 and 7%, respectively. The period between the operation and the first recurrence was approximately 2 (0-9) years and the patients with recurrence died in about 1 (0-9) year. Four patients actually survived more than 10 years after the first recurrence. The recurrence rate after complete surgical resection of lung cancer was 38% in all and it increased along with the advanced pathological stages.

Early and midterm outcomes of triple patch technique for postinfarction ventricular septal defects.

OBJECTIVE: Early and midterm outcomes were evaluated in patients who had postinfarction ventricular septal defect (VSD) and underwent VSD repair using the triple patch technique. METHODS: Twenty-one patients underwent VSD repair for postinfarction VSD between April 2004 and September 2015. A retrospective analysis of all in-hospital and postdischarge data was performed. In addition, we compared pre- and perioperative variables between survivors and nonsurvivors. RESULTS: Thirty-day mortality was 23.8% (5 patients). Three patients died due to low output syndrome and 2 patients died due to sepsis. All of these patients were in cardiogenic shock preoperatively. Although 3 patients had a small residual shunt after surgery, the residual shunt disappeared 6 months after surgery in 1 patient and has been decreasing gradually in another. The mean follow-up was 43.5 ± 36.1 months. Overall survival rates (Kaplan-Meier method) at 3 and 8 years were 70.8% and 57.9%, respectively. Compared with survivors, nonsurvivors had a higher incidence of preoperative cardiogenic shock, higher incidence of chronic kidney disease and end-organ failure, and longer aortic crossclamp times during surgery. CONCLUSIONS: Early and midterm outcomes of modified infarct exclusion using the triple patch technique are acceptable. This technique is safe and simple, and may be useful for reducing postoperative residual shunt.

Floating thrombus originating from an almost normal thoracic aorta.

We present a case of floating thrombus originating from an almost normal thoracic aorta in a 54-year-old man who presented with acute arterial occlusion of his left leg. Transesophageal echocardiography (TEE), computed tomography, and magnetic resonance imaging showed two masses in an almost normal aorta after embolectomy for the acute arterial occlusion. Although the embolus was thrombus histologically, malignant tumors could not be ruled out. The masses did not decrease in size after 7 days of anticoagulant therapy, so they were extirpated under cardiopulmonary bypass (CPB) and TEE guidance. Frozen section examination during CPB indicated that there was no evidence of malignancy in the removed mass. TEE played an important role in the diagnosis and surgery of this condition, and it was useful when deciding on a surgical strategy. Because the treatment strategy for this disease remains controversial, further studies are needed.

Serum erythropoietin level as a marker of limb ischemia.

Bone marrow implantation (BMI) has been utilized for the treatment of limb ischemia, however, serum markers have not yet been reported to express the degree of limb ischemia. We analyzed the serum levels of several cytokines including erythropoietin (EPO) in the treated legs and the contralateral ones in 11 patients with limb ischemia treated with BMI. The EPO level in the pre-treated legs in the 5 patients with arteriosclerosis obliterans revealed a good correlation with ankle-brachial pressure index. The EPO level, but not the levels of TNF-alpha, VEGF, and bFGF in the pre-treated legs was significantly higher than that in the contralateral legs in the 11 patients, and the EPO level decreased in 4 weeks after BMI. The serum EPO level may express the degree of limb ischemia presumably through the reactive production of EPO in ischemic tissue.

[Prognostic factors for critical limb ischemia after autologous bone marrow implantation].

OBJECTIVES: Autologous bone marrow implantation (BMI) is effective to treat critical limb ischemia, but the long-term prognosis is not clear. The outcome of BMI treatment for ischemic legs was investigated related to the clinical background of the patient, and short-term effects of BMI. The end event was defined as unexpected lower limb amputation. METHODS AND RESULTS: This study included 21 consecutive patients (mean age 60.0 +/- 13.6 years) with peripheral arterial disease who underwent BMI between December 2001 and March 2005. Twelve patients had arteriosclerosis obliterans (ASO), 5 had Buerger disease (thromboangiitis obliterans), 3 had thromboembolism, and 1 had hypereosinophilic syndrome. The patients with ASO had severe complications such as diabetes and hyperlipidemia. The total number of transplanted CD34-positive cells, ankle-brachial pressure index (ABI), and tissue oxygen pressure (TcO2) were lower in ASO patients than non-ASO patients. Significant risk factors for the event were diagnosis of ASO and low TcO2 (< 30 mmHg) according to the Kaplan-Meier survival curve and log rank test. All 6 patients who required limb amputation had ASO simultaneously with low TcO2 (6 of 9, 67%). In contrast, there was no correlation between the end event and short-term effect of BMI such as improvements in ABI and TcO2. CONCLUSIONS: Treatment with BMI could not save legs in some patients with ASO associated with severe leg ischemia.

Ruptured aneurysm of the subclavian artery in a patient with von Recklinghausen's disease.

A vascular manifestation of von Recklinghausen's disease is rare, but may be fatal if it is disrupted. A 39-year-old male with von Recklinghausen's disease presented with a large and tender bruise extending from his left neck to his left shoulder and arm. Computerized axial tomography revealed a ruptured aneurysm of the left subclavian artery. The patient underwent emergency surgery to exclude the aneurysm, and cross-over bypass grafting of both subclavian arteries was performed. We present a brief review of vascular maintestation of von Recklinghausen's disease, as well as a discussion regarding the strategy for treating this rare presentation.