[Acute Aortic Dissection Escaping Cardiac Tamponade due to Congenital Pericardial Defect:Report of a Case].

The natural course of Stanford type A acute aortic dissection (AAAD) has a poor prognosis. Early diagnosis is crucial, but in clinical practice some patients do not have typical symptoms, leading to a delay in diagnosis. We encountered a patient who complained only of shoulder pain and moderate respiratory distress. A chest computed tomography( CT) examination showed a dilated ascending aorta and a massive left hemothorax with minimal pericardial effusion. Intraoperative findings revealed aortic dissection of the ascending aorta and a congenital defect on the left pericardium. We performed graft replacement of the aortic root and ascending aorta. Usually, cardiac tamponade is a fatal complication of AAAD. However, in this case, the congenital pericardial defect drained the hemorrhage into the thoracic cavity and relieved cardiac tamponade. AAAD with a congenital pericardial defect may present clinically atypical. In this case, the patient could be saved by surgery without developing circulatory failure due to cardiac tamponade.

[Total Arch Replacement Using Isolation Technique for Giant Thrombus in Ascending Aorta and Aortic Arch:Report of a Case].

We report a case of giant thrombus in the ascending aorta and the aortic arch, and our successful treatment. A 52-year-old man was referred to our department for coldness and numbness of the right upper arm and hand for several days. Contrast enhanced computed tomography revealed thrombosis of the right brachial artery and a giant thrombus in the ascending aorta and the aortic arch. Three days after the revascularization of the right upper limb by thrombectomy, we performed total arch replacement with frozen elephant trunk using "isolation technique" which is reported to be useful to prevent embolic stroke during total arch replacement in patients with shaggy aorta. In this technique brain circulation was isolated by establishing selective cerebral perfusion before starting systemic perfusion. Postoperative course was uneventful and no recurrent thrombosis has been observed for a year with anticoagulant therapy. We advocate that this technique is also useful in the presence of thrombus in the ascending aorta and the aortic arch.

[Surgical Treatment for Giant Coronary Aneurysm Complicated by Acute Myocardial Infarction and Cardiopulmonary Arrest:Report of a Case].

Giant coronary aneurysm is rare, but a life-threatening disease. We report a 67-year-old man with 39 mm coronary aneurysm. He was presented to our facility with acute coronary syndrome complicated by cardiogenic shock. Angiography demonstrated giant coronary aneurysm and occlusion of the right coronary artery. After cardiopulmonary resuscitation and cardiopulmonary support (PCPS), emergent excision of aneurysm and coronary artery bypass grafting was performed. The postoperative course was good without complications. Most giant coronary artery aneurysms are asymptomatic but some patients present with angina pectoris, sudden death, fistula formation, pericardial tamponade, compression of surrounding structures, or congestive heart failure. But once complications, such as thrombosis, distal embolization, fistula formation or rupture occurred, it is difficult to save life without aggressive surgery. At present, there are no specific guidelines for the treatment of giant coronary aneurysm. Surgical correction is a preferred approach for the treatment of giant coronary artery aneurysms.

The Plasmodium apicoplast genome: conserved structure and close relationship of P. ovale to rodent malaria parasites.

Apicoplast, a nonphotosynthetic plastid derived from secondary symbiotic origin, is essential for the survival of malaria parasites of the genus Plasmodium. Elucidation of the evolution of the apicoplast genome in Plasmodium species is important to better understand the functions of the organelle. However, the complete apicoplast genome is available for only the most virulent human malaria parasite, Plasmodium falciparum. Here, we obtained the near-complete apicoplast genome sequences from eight Plasmodium species that infect a wide variety of vertebrate hosts and performed structural and phylogenetic analyses. We found that gene repertoire, gene arrangement, and other structural attributes were highly conserved. Phylogenetic reconstruction using 30 protein-coding genes of the apicoplast genome inferred, for the first time, a close relationship between P. ovale and rodent parasites. This close relatedness was robustly supported using multiple evolutionary assumptions and models. The finding suggests that an ancestral host switch occurred between rodent and human Plasmodium parasites.

Effects of atrial natriuretic peptide after prolonged hypothermic storage of the isolated rat heart.

Primary graft failure (PGF) caused by ischemia-reperfusion injury (IRI) is the strongest determinant of perioperative mortality after heart transplantation. Atrial natriuretic peptide (ANP) has been found to reduce the IRI of cardiomyocytes and may be beneficial in alleviating PGF after heart transplantation, although there is a lack of evidence to support this issue. The purpose of this study was to investigate the cardioprotective effects of ANP after prolonged hypothermic storage. For this purpose, an isolated working-heart rat model was used. After the preparation, the hearts were arrested with and stored in an extracellular-based cardioplegic solution at 3-4°C for 6 h and followed by 25 min of reperfusion. The hearts were divided into four groups (n = 7 in each group) according to the timing of ANP administration: Group 1 (in perfusate before storage), Group 2 (in cardioplegia), Group 3 (in reperfusate), and control (no administration of ANP). Left ventricular functional recovery and the incidence of ventricular fibrillation (VF) were compared. ANP administration at the time of reperfusion improved the percent recovery of left ventricular developed pressure (control, 45.5 ± 10.2; Group 1, 47.4 ± 8.8; Group 2, 45.3 ± 12 vs. Group 3, 76.3 ± 7; P < 0.05) and maximum first derivative of the left ventricular pressure (control, 47.9 ± 8.7; Group 1, 46.7 ± 8.8; Group 2, 49.6 ± 10.8 vs. Group 3, 76.6 ± 7.5; P < 0.05). The incidence of VF after reperfusion did not differ significantly among these four groups (71.4, 85.7, 57.1, and 85.7% in Groups 1, 2, 3, and control, respectively). This result suggests that the administration of ANP at the time of reperfusion may have the potential to decrease the incidence of PGF after heart transplantation.

Intravascular ultrasound complements the diagnostic capability of carbon dioxide digital subtraction angiography for patients with allergies to iodinated contrast medium.

Carbon dioxide digital subtraction angiography (CO(2)DSA) is a useful and safe alternative for patients with renal dysfunction or allergies to iodinated contrast medium. However, CO(2)DSA image quality is worse than that of angiography with iodinated contrast medium, primarily because of movement during imaging and stent struts. In angioplasty of arteries of the lower extremities, CO(2)DSA cannot be used to sufficiently evaluate target lesions and determine the most efficient intervention. However, in the current case report, we describe a patient with severe allergies to iodinated contrast medium (Stevens-Johnson syndrome), because of which we were unable to use any iodinated contrast medium when conducting angioplasty. Therefore, we used intravascular ultrasound (IVUS), which facilitated the complete observation of the target lesion after stent implantation without requiring iodinated contrast medium. In this case, IVUS was used to complement the diagnostic capabilities of CO(2)DSA.

Atrionatriuretic peptide improves left ventricular function after myocardial global ischemia-reperfusion in hypoxic hearts.

Atrionatriuretic peptide (ANP) is reported to be useful for attenuating myocardial ischemia-reperfusion injury and improving left ventricular function after reperfusion. However, ANP may be either ineffectual or harmful in cases where the myocardium has been chronically hypoxic since birth. This can be a result of the concomitant high levels of cyclic guanosine monophosphate (cGMP) produced within the myocardium. This study aimed to verify the validity of using ANP to improve left ventricular function after myocardial ischemia-reperfusion injury. For this purpose, a cyanotic congenital disease model that was developed using isolated rat hearts was used. Hearts were obtained from Sprague-Dawley rats that were housed from birth until 6 weeks of age either in a hypoxic environment with 13-14% FiO(2) (hypoxic group) or in ambient air (normoxic group). These hearts were subjected to 30min of normothermic global ischemia followed by 30min of reperfusion using the Langendorff technique. Left ventricular functional recovery in hearts administered ANP (0.1µM) into the reperfusion solution was compared with those hearts that were not administered ANP in both hypoxic (without ANP: n=6, with ANP: n=6, with ANP and HS-142-1[an antagonist of ANP]: n=6) and normoxic hearts (without ANP: n =6, with ANP: n=6). In the hypoxic hearts, ANP administration improved the percent recovery of the left ventricular developed pressure (76.3±9.2% without ANP vs. 86.9±6.7% with ANP), maximum first derivative of the left ventricular pressure (82.4±1.1% without ANP vs. 95.8±6.5% with ANP), and heart rate (85.6±4.7% without ANP vs. 96.1±5.2% with ANP) after reperfusion. The improvement and recovery of these cardiac functions were closely related to significantly increased levels of postischemic cGMP release after ANP administration. The effect of ANP was blocked by HS-142-1. The improvements observed in the hypoxic group were similar to those found in the normoxic group. ANP administration during reperfusion improved left ventricular function after myocardial acute global ischemia-reperfusion equally in both the chronically hypoxic and age-matched normoxic groups.

Treponemes-infected canker in a Japanese racehorse: efficacy of maggot debridement therapy.

A 3-year-old thoroughbred colt presented with canker on its left hind foot. Subsequent development of cottage cheese-like horns and dermatitis disturbed healing, despite the use of miscellaneous orthodox treatment approaches to the lesions. Histological examination revealed exudative and suppurative dermatitis, and proliferatively suppurative epidermitis infected with helically coiled treponemes. Total debridement under general anesthesia led to a temporary improvement, but the ground surface regenerated abnormal epidermis similar to that observed initially after surgery. Maggot debridement therapy (MDT) was attempted, which removed all the abnormal tissue. After MDT, general farriery trimming helped to correct the distorted ground surface, and the horse returned to constant training and eventually raced. This case shows that MDT was successfully used for treatment of an intractable and treponemes-infected canker.

Suture retention strength of expanded polytetrafluoroethylene (ePTFE) graft.

Our meticulous investigation of ePTFE graft breakage when a wire placed at the edge of an ePTFE graft was pulled, revealed that, depending on the breakage pattern, a break starts much earlier than the peak suture retention strength, which is the current international indicator for anastomotic-site break strength. Furthermore, the breakage patterns differ based on the thickness of the wire and the fiber direction of the ePTFE graft. Based on these findings, we advocate measuring the peak suture retention strength using 0.10-mm sutures and a standardized wire thickness in order to assess the anastomotic retention strength of ePTFE grafts.

Successful intra-postoperative extracorporeal circulatory support with atrial communication for treatment of anomalous left coronary artery from the pulmonary artery: a case report.

We describe a successful case of surgical treatment for anomalous left coronary artery from the pulmonary artery (ALCAPA) syndrome with severe left ventricular dysfunction. Because of the severe left ventricular dysfunction, we planned to use an extracorporeal membrane oxygenation for heart support until a satisfactory recovery had been established. The left ventricular function significantly recovered in a few days, and the patient could be discharged without any complications.

Surgical repair of axillary graft stump syndrome: report of two cases.

Late upper extremity embolic complications of occluded axillofemoral bypass graft (AxFG) or occluded axillo- axillary bypass graft (AxAG) are not frequently noted. A patient presented with acute right upper extremity thromboembolism 2 years after an AxFG occlusion. Computed tomography (CT) findings revealed kinking and occlusion of the axillary artery at the anastomosis. Another patient presented with acute left upper extremity thromboembolism 2 years and 6 years after an AxAG occlusion. CT indicated a thrombus progressing from the occluded graft to the axillary artery. Surgical repair of the axillary artery was performed in both patients without any complications.

Patient with a massive idiopathic thrombosis in the inferior vena cava.

A 50 year-old man with no significant medical history was admitted for dyspnea and left femoral swelling. Contrast-enhanced computed tomography revealed pulmonary thromboembolism (PTE) and a thrombus in the inferior vena cava (IVC). The thrombus extended from the proximal IVC to the left popliteal vein. Therefore, we decided that an IVC filter insertion was difficult to indicate. Urgent IVC and peripheral vein thrombectomy was performed under cardiopulmonary bypass. On postoperative day 1, venous ultrasonography showed residual deep vein thrombosis in the left external iliac-femoral vein and the popliteal vein. The IVC filter insertion was performed to prevent the recurrence of PTE.

Tolerance of the developing cyanotic heart to ischemia-reperfusion injury in the rat.

OBJECTIVE: Whether chronic hypoxia attenuates myocardial ischemia-reperfusion injury remains controversial because conflicting data have been reported probably due to the existence of many factors influencing the functional recovery of hearts. These factors include the differences of species, the time at which hypoxia begins, the degree of hypoxia, and so on. Regarding chronic hypoxia from birth, so far the only available data are based on findings in rabbit hearts. The purpose of this study was to describe the effect of chronic hypoxia from birth on myocardial reperfusion injury in the rat heart. METHODS: Normoxic hearts were obtained from rats housed in ambient air for 6 weeks (normoxic group); hypoxic hearts were obtained from rats housed in a hypoxic chamber (13%-14% oxygen) from birth for 6 weeks (hypoxic group). Isolated, crystalloid perfused working hearts were subjected to 30 min of global normothermic ischemia followed by 15 min of reperfusion; functional recovery was then measured in the two groups. The excretion of cyclic guanosine monophosphate (cGMP) in the coronary drainage was measured at the end of the preischemia and reperfusion periods. RESULTS: The percent recovery of the left ventricular developed pressure and the first derivative of left ventricular pressure were significantly better in the hypoxic group than in the normoxic group. cGMP excretion in the coronary drainage was significantly increased during both the preischemia and reperfusion periods. CONCLUSION: Chronic hypoxia from birth increased myocardial tolerance to ischemia-reperfusion injury with increased cGMP synthesis in the isolated heart model in rats.

Phylogeny of Asian primate malaria parasites inferred from apicoplast genome-encoded genes with special emphasis on the positions of Plasmodium vivax and P. fragile.

Phylogenetic analyses of several marker genes have previously shown that Asian primate Plasmodium species (malaria parasites) were monophyletic including Plasmodium vivax, one of the four malaria parasites that infect humans. However, except for the presence of a few established groupings, phylogenetic relationships among the Asian primate Plasmodium species + P. vivax group have neither been clearly resolved with confident statistical supports, nor the closest relative to P. vivax was elucidated. Since comparative biological studies between P. vivax and its closest relative would provide valuable information on immunopathogenesity of vivax malaria, the phylogenetic positions of P. vivax in the clade comprised of Asian primate Plasmodium species are crucial. In order to clarify the phylogeny and evolution of Asian primate Plasmodium species including P. vivax, we obtained sequences of apicoplast genome-encoded genes for small subunit rRNA (SSUrRNA), large subunit rRNA (LSUrRNA), and caseinolytic protease C (ClpC) from 10 Plasmodium species: P. vivax, P. coatneyi, P. cynomolgi, P. fieldi, P. fragile, P. hylobati, P .inui, P. knowlesi, P. simiovale, and P. gonderi. Together with published sequences of apicoplast genome-encoded elongation factor Tu (EF-Tu) from these species, we performed phylogenetic analyses of a combined 4-gene data set using P. gonderi, an African old world monkey parasite, as an outgroup. The ML phylogeny based on a 'concatenate model' for combining information of the 4 genes clearly revealed close relationships between P. vivax and P. cynomolgi and monophyly of P. fragile with the P. coatneyi/P. knowlesi clade. When 'separate' models were assumed for combining phylogenetic information from the 4 genes that were independently analyzed, the support for the P. vivax/P. cynomolgi clade was substantially decreased, but the monophyly of P. fragile with the P. coatneyi/P. knowlesi clade was still robustly confirmed. The present analyses place P. fragile in a position that is incongruent with the early branching status of P. fragile amongst P-vivax-related primate Plasmodium species propose by Escalante et al. (Proc Natl Acad Sci USA 2005 102: 1980).

Blunt cardiac rupture in a patient with a history of total correction of tetralogy of Fallot.

A 35-year-old man with a history of total correction of tetralogy of Fallot (TOF) fell down while riding a bike and experienced blunt cardiac rupture. His vital signs were stable because the bleeding was limited by an adhesion caused by the previous operation. Chest computed tomography clearly displayed the ruptured points, and an emergency operation was performed. Because a pneumothorax was suspected, a cardiopulmonary bypass was established with a femorofemoral bypass while the patient was conscious before artificial ventilation was initiated. Two ruptured points were detected on the anterior wall of the right ventricle and were repaired by suturing. The patient recovered and was discharged without any major complications 40 days after the operation. This is the first published case of blunt cardiac rupture after total correction of TOF.

Apicoaortic bypass using a vascular graft with a bioprosthetic valve.

We report a case of 75-year-old man who underwent an apicoaortic bypass for severe aortic stenosis. The patient had a porcelain aorta accompanied by a severely calcified aortic annulus. We used a woven polyester vascular graft instead of a rigid apical connector because the latter material cannot be obtained in Japan. Postoperative examination showed no compression or stenosis in the apical outflow. A woven polyester vascular graft is therefore considered suitable for an apicoaortic bypass.