Primary Percutaneous Coronary Intervention Followed by Valve Surgery for Acute Coronary Syndrome at Left Main Trunk Complicated With Severe Aortic Stenosis.

An 89-year-old woman appeared to have acute coronary syndrome at the left main trunk (LMT) complicated with severe aortic stenosis, moderate-severe mitral regurgitation, depressed left ventricular (LV) function, and multivessel disease. Because of sustained hypotension even under intra-aortic balloon pumping support during emergency coronary angiograhy, we performed primary percutaneous coronary intervention solely for the LMT lesion using a bare metal stent, leading to recovery from the shock state. On the second hospital day, based on our heart-team consensus, we performed aortic valve replacement and coronary artery bypass grafting surgery, and added edge-to-edge repair (Alfieri stitch) of the mitral valve, resulting in complete revascularization and dramatically improved LV function.

Two-stage hybrid repair of Kommerell diverticulum with supra-aortic debranching.

OBJECTIVES: The surgical treatment of Kommerell diverticula is associated with high mortality and morbidity rates. In the mid-2000s, hybrid aortic arch repair was developed, and the procedure has since been used to repair Kommerell diverticula. In the present study, we focused on the postoperative outcomes of two-stage hybrid repair of Kommerell diverticula that required supra-aortic debranching (type I hybrid arch repair). METHODS: From August 2010 to July 2013, a total of four patients (aged 73.5 ± 9.5 years) underwent two-stage hybrid repair (type I hybrid arch repair) for Kommerell diverticula, and their cases were retrospectively studied. All four patients had right aortic arches and aberrant left subclavian arteries. The repair procedure consisted of two stages: (1) debranching of the supra-aortic vessels via a median sternotomy; (2) exclusion of the Kommerell diverticulum by performing thoracic endovascular repair via a femoral approach and coil embolization of the orifice of the aberrant subclavian artery. RESULTS: There were no in-hospital deaths. One patient developed an acute kidney injury and required hemodialysis on postoperative day 2, although his renal function recovered within 48 hours. No strokes, paraplegia, or early aortic events were observed in our series. The mean follow-up period was 19.5 months (range, 5-47 months). All patients remained free from aortic events and endoleaks during the follow-up period. CONCLUSION: The early and mid-term outcomes of hybrid repair for Kommerell diverticula that require supra-aortic debranching, which are less invasive and do not involve hypothermic circulatory arrest, are acceptable. However, this procedure requires the insertion of an endograft into the ascending aorta, and careful and long-term follow-up is required to confirm its efficacy.

Right coronary ischaemia caused by a sinus of Valsalva aneurysm improved by releasing mechanical stretch: a case report.

Background: A sinus of Valsalva aneurysm involving a single cusp is a rare condition, and coronary computed tomography angiography with fractional flow reserve-computed tomography helps evaluate not only the anatomical aspects of the aneurysm and coronary artery but also the physiological details of coronary artery disease. Case summary: A 71-year-old woman presented with exertional chest pain and dyspnoea. Enhanced computed tomography revealed an aneurysmal change in the right sinus of Valsalva, and coronary computed tomography angiography revealed diffuse narrowing of the proximal segment of right coronary artery due to mechanical stretching by the large Valsalva aneurysm. Fractional flow reserve-computed tomography revealed a significantly low fractional flow reserve (0.50 in the distal right coronary artery). A modified Bentall procedure was performed with a 21 mm bioprosthetic valve and a 24 mm Valsalva graft conduit for the aortic root aneurysm; mitral valve annuloplasty was performed for mitral valve regurgitation. Post-operative coronary computed tomography angiography revealed no significant stenosis in the proximal segment of the right coronary artery. Furthermore, fractional flow reserve-computed tomography revealed a normalized fractional flow reserve in the distal right coronary artery. The patient experienced relief from chest pain and was discharged 19 days after the surgery. Discussion: A right coronary sinus of Valsalva aneurysm, which caused right coronary artery ischaemia, was successfully treated using a modified Bentall procedure. Coronary computed tomography angiography and fractional flow reserve-computed tomography revealed anatomical and functional improvements in the right coronary artery ischaemia post-operatively.

[A case of cerebral embolism treated with early surgical intervention for aneurysm of sinus of Valsalva as embolic source].

The patient was a 78-year-old man. He was transferred to the emergency room presenting with aphasia and right hemiplegia. Head CT and CT angiography demonstrated a narrow territory of early ischemic signs and occlusion of the horizontal segment of the left middle cerebral artery (MCA), respectively. Endovascular thrombectomy was performed and complete recanalization of MCA was achieved. After admission, transthoracic echocardiography revealed a cystic mass near the left coronary apex of the aortic valve, which was diagnosed as an aneurysm of the sinus of Valsalva (ASV) by contrast-enhanced chest computed tomography. Transesophageal echocardiography showed a severe smoke-like echo within ASV, despite being in sinus rhythm. Intravenous anticoagulant therapy was started, and patch closure was performed by cardiovascular surgeons on the 13th day despite of early period after stroke onset. During the operation, no thrombus was seen around the inlet of ASV. On the two days after the operation, paroxysmal atrial fibrillation was detected and anticoagulant therapy was continued. In this patient, ASV was regarded as the embolic source of cerebral embolism, and anticoagulant therapy and surgical intervention were selected in the early period after stroke onset to prevent embolism recurrence, resulting in a favorable clinical course.

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.

Inferior vena caval thrombosis complicating pyogenic liver abscess after pancreatoduodenectomy: a case report.

Pyogenic liver abscess (PLA) complicated by inferior vena caval (IVC) thrombosis is rare but life-threatening. We experienced a case of PLA complicated by an IVC thrombus close to the right atrium after pancreatoduodenectomy. A 75-year-old man had undergone pancreatoduodenectomy with modified-Child reconstruction for pancreatic cancer 3 years prior, and no recurrence was noted on follow-up. He was admitted to our hospital owing to fever and general fatigue. PLA and septic shock were diagnosed, and conservative therapy with antibiotics was initiated. His general condition gradually improved, but a thrombus in the middle hepatic vein and IVC was noted on follow-up computed tomography on hospital day 8. Although anticoagulant therapy using heparin was started, the thrombus size increase and extended to the right atrium. Considering the risk of pulmonary embolism, we planned a surgical intervention with a cardiovascular surgeon to remove the thrombus. During surgery, we made an incision in the right atrium and removed the thrombus using extracorporeal circulation. After removal, we dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the IVC. The patient was discharged 10 weeks after surgery. Eighteen months post-intervention, there was no recurrence of either PLA or thrombi. Our experience suggests that physicians should consider the existence of a middle hepatic vein and IVC thrombi when examining PLA patients and that surgical intervention can be applied successfully in such cases.

Coronary artery obstruction due to membranous ridge of the right sinus valsalva associated with Tetralogy of Fallot: syncope mimics anoxic spell.

We report an infant with Tetralogy of Fallot who had suffered from repetitive attacks of syncope without obvious cyanosis. Careful observation by means of echocardiography and angiography revealed that the attacks resulted from acute coronary artery obstruction due to membranous ridge covering the sinus Valsalva. Surgical resection of the abnormal ridge and repair of Tetralogy of Fallot successfully improved the patient's symptoms. Syncope in children should be extensively investigated to exclude obstruction of the coronary arteries.

Anterior translocation of the right pulmonary artery for airway obstruction caused by pulmonary hypertension.

Both the bronchi are often severely squeezed by the dilated pulmonary artery in infants with ventricular septal defect and pulmonary hypertension. To relieve the considerable residual airway obstruction, the right pulmonary artery is translocated anteriorly to the ascending aorta concomitantly with the intracardiac repair. This technique is a useful procedure for infants with intractable respiratory failure caused by a dilated pulmonary artery.

Oxidative stress-induced apoptosis is associated with alterations in mitochondrial caspase activity and Bcl-2-dependent alterations in mitochondrial pH (pHm).

Oxidative stress, the result of cellular production of reactive oxygen species (ROS), has been implicated in a number of diseases of the eye. Exposure of eye tissues (e.g. the cornea and retina) to oxidative stress over time has been hypothesized to underlie the development of age-related macular degeneration (AMD) and maturity onset cataract formation. Light-induced free radicals can damage the eye, and alterations in the antioxidant defenses of the eye have been suggested to play a role in the etiology of glaucoma. Mitochondria are both a major endogenous source and target of ROS, and oxidative stress has been shown to induce apoptotic cell death by targeting the mitochondria directly. Mitochondrial-dependent apoptosis has been shown to require release of cytochrome c from mitochondria and subsequent activation of a specific class of cytoplasmic proteases known as caspases. Bcl-2, an anti-apoptotic protein localized to mitochondria, has been shown to inhibit cytochrome c release and protect against oxidative stress-induced apoptosis. Here we demonstrate that oxidative stress causes activation of mitochondrial matrix caspase-2 and -9 activity that is associated with Bcl-2-inhibitable acidification of mitochondrial pH (pH(m)). In conjunction with recent reports that caspase activation is maximal at acidic pH, these findings have led us to hypothesize that Bcl-2 may modulate cytochrome c release following oxidative stress by modifying the pH-dependent activation of mitochondrial caspase activity. These studies provide an increased understanding of the mechanism(s) by which oxidative stress damages tissues, and may have important therapeutic implications for treatment of opthamological diseases.

Usefulness of multidetector computed tomography for diagnosis and surgical treatment of large coronary artery fistula.

BACKGROUND: Coronary angiography (CAG) has been the mainstay of diagnostic image analysis for coronary artery fistula (CAF). However, it is difficult to fully delineate this complex vessel structure including coronary trees, particularly in cases with large CAF, by this method. CASE REPORTS: In the present 3 cases with large CAF, contrast-enhanced multidetector computed tomography (MDCT) was performed to examine the whole coronary vessel structure including CAF. Selective CAG was also undertaken. In all 3 cases, based on the echocardiographic findings and the characteristic heart murmur, presence of CAF was suspected. However, transthoracic echocardiography as well as CAG alone could not define the whole abnormal vessel structure precisely. Moreover, CAG could not obtain clear images of the coronary artery with large CAF, because of contrast-steal. In contrast, MDCT could not only define CAF in detail but also depict coronary artery adjacent to CAF. On the basis of the MDCT findings, in cases 1 and 3, surgical exclusions were undertaken without and with coronary artery bypass grafting, respectively. CONCLUSIONS: Contrast-enhanced MDCT might be useful for the diagnosis of large CAF and for the estimation of the coronary artery adjacent to CAF, which is absolutely indispensable for surgical treatment.

Computer-simulated bone architecture in a simple bone-remodeling model based on a reaction-diffusion system.

Bone is a complex system with functions including those of adaptation and repair. To understand how bone cells can create a structure adapted to the mechanical environment, we propose a simple bone remodeling model based on a reaction-diffusion system influenced by mechanical stress. Two-dimensional bone models were created and subjected to mechanical loads. The conventional finite element method (FEM) was used to calculate stress distribution. A stress-reactive reaction-diffusion model was constructed and used to simulate bone remodeling under mechanical loads. When an external mechanical stress was applied, stimulated bone formation and subsequent activation of bone resorption produced an efficient adaptation of the internal shape of the model bone to a given stress, and demonstrated major structures of trabecular bone seen in the human femoral neck. The degree of adaptation could be controlled by modulating the diffusion constants of hypothetical local factors. We also tried to demonstrate the deformation of bone structure during osteoporosis by the modulation of a parameter affecting the balance between formation and resorption. This simple model gives us an insight into how bone cells can create an architecture adapted to environmental stress, and will serve as a useful tool to understand both physiological and pathological states of bone based on structural information.

One-stage unifocalization and palliative right ventricular outflow tract reconstruction.

We report a successful case of one-stage unifocalization concomitant with palliative right ventricular outflow tract reconstruction for pulmonary atresia and ventricular septal defect with major aortopulmonary collateral arteries and central pulmonary arterial absence. Through a median sternotomy, one-stage unifocalization was accomplished using autologous pericardial conduit and no prosthetic material. To achieve an adequate pulmonary blood flow, the right ventricular outflow tract was reconstructed so that it would be 70% of the normal pulmonary annular diameter, while the ventricular septal defect was left open. One-stage unifocalization concomitant with palliative right ventricular outflow tract reconstruction is considered to be a good surgical option for selected patients with these diseases.