Thoracic endovascular aortic repair with a right thoracotomy approach.

BACKGROUND: The common femoral artery is usually the preferred access route for thoracic endovascular aortic repair (TEVAR). However, if access from the common femoral artery is challenging, other routes must be considered. We report a case of TEVAR performed by approaching the descending thoracic aorta with a right thoracotomy and using the descending thoracic aorta as an access route. CASE PRESENTATION: A 70-year-old female was diagnosed with a descending thoracic aortic aneurysm (65 mm in diameter), a thoracoabdominal aneurysm (54 mm in diameter), and an abdominal aortic aneurysm (49 mm in diameter). Since the patient had severe chronic obstructive pulmonary disease, one-stage replacement of the thoracoabdominal aortic aneurysm was contraindicated and TEVAR on the descending aorta was selected. A strong tortuous section of the aorta-from the descending aorta to the abdominal aorta-hampered endovascular access to the site from the common femoral artery. A TEVAR approach from the abdominal aorta was also considered; however, an abdominal aortic aneurysm and a transverse colon loop stoma from an earlier surgery presented challenges to this technique. We chose to access the descending thoracic aorta with a thoracotomy from the right 6th intercostal space for TEVAR, because the access route that is not affected by the meandering of the aorta is considered to be the descending aorta with a right thoracotomy. The patient's postoperative course was uneventful after the stent graft was placed. No complications were detected with postoperative contrast-enhanced computed tomography (CT). CONCLUSIONS: Our findings suggest that TEVAR can be performed by approaching the descending aorta from a right thoracotomy, if variations of vascular anatomy interfere with the more commonly used femoral artery approach.

[Prediction of Length of Artificial Chordae by Using Preoperative Cardiac Computed Tomography:Report of a Case].

A 51-year-old man was diagnosed as having mitral valve regurgitation( MR). Transesophageal echocardiography revealed severe MR due to A2 prolapse. We decided to perform a mitral valve plasty (MVP). The length of an artificial chord was estimated by measuring the distance from the anterior and posterior papillary muscles to A2 on cardiac computed tomography (CT). The operation was performed with a median sternotomy. The leaflet prolapse lesion was localized in A2, and one torn chord was revealed. Polytetrafluoroethylene sutures were fixed to the papillary muscle, and markings were performed. After fixing the artificial chord to A2 in the predicted length before the operation, a leakage test was performed. We confirmed that the MR had disappeared. The postoperative course was good, and no MR was detected upon postoperative echocardiography. Preoperative prediction of the artificial chord length using cardiac CT is useful because it can be adjusted relatively easily.

Change in the electronic structure of the bismuth chalcogenide superconductor CsBi4-x Pb x Te6 by dissociation of the bismuth dimers.

CsBi4-x Pb x Te6 is synthesized and the superconductivity associated with the structural transition from Pb substitution is studied. Photoemission spectroscopy measurements are performed in order to elucidate the relationship between the electronic structure and the occurrence of the superconductivity. When Bi is substituted with Pb, an electron doping-like change in the electronic structure is directly observed which is contrary to the naive expectation of hole doping. This observation is consistent with band structure calculations and appears to be a unique characteristic of CsBi4-x Pb x Te6 because of the dissociation of Bi dimers upon Pb substitution. These results indicate that it may be possible to control the electron and hole doping via manipulating the Bi dimers through Pb substitution.

Stent grafting simulation using a three-dimensional printed model for extensive aortic arch repair combined with coarctation.

Stent grafting for complex aortic anatomy remains a challenge. In particular, stent graft collapse (i.e. infolding) is possible when an excessive oversized device is needed. We describe a case of preoperative stent grafting simulation using a three-dimensional (3D) printed model for extensive aortic arch repair in a 69-year-old woman with multiple aneurysms combined with coarctation. The patient was scheduled to undergo staged hybrid repair. A stent graft larger than 28 mm in diameter was needed to deploy into a coarctation of 15 mm in diameter during the 2nd stage of the operation. Preoperative, experimental stent grafting using a 3D printed model indicated that infolding would likely not occur. Therefore, we proceeded with surgery, which was successful. This technology could be a useful application for planning complicated stent grafting.

Diabetes mellitus adversely affects mortality and recurrence after valve surgery for infective endocarditis.

BACKGROUND: Although diabetes mellitus (DM) increases the incidence of infective endocarditis (IE), little is known about the outcome of valve surgery for active IE in patients with DM. We evaluated the clinical outcomes of valve surgery for IE in patients with DM. METHODS: Between 2009 and 2016, 470 patients underwent valve surgery for definitive left-sided active IE at 12 affiliated hospitals. We compared the preoperative variables and clinical outcomes between patients without (n = 374) and with DM (n = 96). RESULTS: Staphylococcus and chronic hemodialysis were more prevalent in patients with DM, and these patients had greater preoperative inflammation levels and worse renal function than patients without DM. In-hospital mortality was 8% in patients without DM and 13% in patients with DM (P = .187). The overall survival rate at 1 and 5 years was 87% and 81% in patients without DM and 72% and 59% in patients with DM (P < .001). The incidence of infection-related death was greater in patients with DM than in patients without DM (P < .001; hazard ratio 3.74 [1.78-7.71]). Freedom from the recurrence of endocarditis at 1 and 5 years postoperatively was 98% and 95% in patients without DM, and 89% and 78% in patients with DM (P < .001), respectively. The Cox hazard analysis revealed that the presence of DM was the only independent risk for recurrence (hazard ratio 3.74 [1.45-9.54], P = .007). CONCLUSIONS: The short- and mid-term outcome after valve surgery for active IE in patients with DM is worse because of the greater prevalence of infection-related death and IE recurrence.

Immunoglobulin G4-related disease of the thickened aortic valve extending to the left ventricular outflow tract causing severe aortic regurgitation and complete atrioventricular block: a case report.

BACKGROUND: Immunoglobulin G4-related disease (IgG4-RD) is a systemic disease characterized by the tumefactive lesions and infiltration of IgG4-positive plasma cells. IgG4-RD has been described in various organs, but rarely the aortic valve. There are only a few reports of aortic stenosis, and none on significant aortic regurgitation. In addition, previous case reports relating to aortic valve lesions led to surgery as a first-line treatment. The effect of steroid treatment has not yet been determined. CASE SUMMARY: A 62-year-old man, receiving steroid therapy, who presented with general malaise, shortness of breath, and bradycardia. He had suspected IgG4-RD because of pancreatitis, lacrimal gland enlargement, and retroperitoneal fibrosis. An examination revealed a thickened aortic valve extending to the left ventricular outflow tract with severe aortic regurgitation and complete atrioventricular block. He received intensive steroid therapy for a suspected IgG4-related aortic valve lesion. The complete atrioventricular block improved, but worsening aortic regurgitation caused congestive heart failure. He required replacement of the aortic valve. A histopathological examination of the excised aortic valve leaflets revealed IgG4-positive lymphoplasmacytic infiltration with fibrotic tissue. The prosthetic valve was functioning well without leakage around the valve at the 1-year follow-up. DISCUSSION: This case highlights the rare possibility that IgG4-RD of the aortic valve also causes significant aortic regurgitation. Conservative treatment with steroids may induce regression of the lesion and contribute to the stability of the prosthetic valve after surgery, but it may also exacerbate heart failure due to the progression of aortic regurgitation in patients with aortic valve lesions.

Late Sac Behavior after Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm.

BACKGROUND: Sac behavior after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) is considered as a surrogate for the risk of late rupture. The purpose of the study is to assess the sac behavior of AAAs after EVAR. METHODS AND RESULTS: Late sac enlargement (LSE) (≥5 mm) and late sac shrinkage (LSS) (≥5 mm) were analyzed in 589 consecutive patients who were registered at 14 national centers in Japan. The proportions of patients who had LSE at 1, 3 and 5 years were 2.6% ± 0.7%, 10.0% ± 1.6% and 19.0% ± 2.9%. The proportions of patients who had LSS at 1, 3 and 5 years were 50.1% ± 0.7%, 59.2% ± 2.3% and 61.7% ± 2.7%. Multiple logistic regression analysis identified two variables as a risk factor for LSE; persistent endoleak (Odds ratio 9.56 (4.84-19.49), P <0.001) and low platelet count (Odds ratio 0.92 (0.86-0.99), P = 0.0224). The leading cause of endoleak in patients with LSE was type II. CONCLUSIONS: The incidence of LSE is not negligible over 5 year period. Patients with persistent endoleak and/or low platelet count should carefully be observed for LSE. CLINICAL TRIAL REGISTRATION: UMIN-CTR (UMIN000008345).

Rupture of an extended mycotic aneurysm of the descending thoracic aorta in a multiple myeloma patient undergoing anti-myeloma therapy.

Infectious complications in patients with multiple myeloma remain the main cause of mortality because of disease-related immunodeficiency. A mycotic aortic aneurysm caused by Burkhoderia cepacia, which has been recognized as nosocomial pathogen in immunocompromised populations, is very rare and only few cases have been reported in the literature. We describe an unusual case of a ruptured mycotic aneurysm of the descending thoracic aorta with a DeBakey IIIb aortic dissection caused by Burkhoderia cepacia in a patient with active multiple myeloma during chemotherapy with anti-myeloma agents. Successful treatment of this mycotic aneurysm included appropriate antibiotic therapy and replacement of the aortic arch and the descending aorta for the extensive debridement of all infected aortas. This was followed by the wrapping of a prosthetic graft with a well-vascularized tissue flap of the greater omentum and of the latissimus dorsi muscle.

[Prosthetic Valve Endocarditis using Immunosuppressive Agent for Atopic Dermatitis;Report of a Case].

A 26-year-old man had a history of severe atopic dermatitis. He was taking immunosuppressive drug. Mitral valve replacement (MVR) had been performed for infective endocarditis March 2008. He came to our hospital in July 2012 complaining of fever of 39 degrees Celsius. According to computed tomography (CT) and transesophageal echocardiography (TEE), we diagnosed that he had cerebral embolism and bacterial infection of prosthetic valve. Antibiotic treatment was performed for 2 weeks after the onset of cerebral infarction. Then we conducted re-MVR. The postoperative course was satisfactory. He showed a gradual improvement in the level of consciousness and was discharged. In patients with atopic dermatitis, bacteria can penetrate into the blood from the skin easily. So they are often affected by bacteremia. There are some reports that infective endocarditis is likely to occur in immunosuppressed patients. It is suggested that immunosuppressive drug was involved in the development of prosthetic valve endocarditis (PVE) in addition to atopic dermatitis in this patient.

BioGlue® coronary embolism during open heart surgery.

In cases of iatrogenic coronary embolism during cardiac surgery or percutaneous coronary intervention, small air bubbles or foreign bodies are directly injected, which usually result in serious adverse events if not treated promptly. We herein describe the case of a patient who developed acute myocardial infarction resulting in shock due to BioGlue® (CryoLife, Atlanta, GA, USA)-induced coronary embolism during the surgical repair of aortic dissection and was treated for retrieval of the material using a thrombectomy catheter. .

Aortic arch surgery with a single centrifugal pump for selective cerebral perfusion and systemic circulation.

In aortic arch surgery, two pumps are required for systemic perfusion and selective cerebral perfusion (SCP). A new technique with a single centrifugal pump for systemic perfusion and SCP was developed and its efficacy and safety evaluated. This technique was adopted for total arch replacement in 22 consecutive patients with true aneurysms (13) and aortic dissection (nine) from January 2005 to January 2008. Cerebral perfusion lines branched from the main perfusion line. During SCP, right radial arterial pressure was maintained at 50 mm Hg and left common carotid arterial pressure at 60 mm Hg, and the regional cerebral oxygen saturation (rSO(2)) values were maintained at approximately >80% of the baseline value. Two operative deaths (9%) occurred due to pneumonia and hemorrhage in the left lung, respectively. Stroke occurred in one patient (5%). This simple circuit system can thus be easily and safely applied for aortic arch surgery.

[One stage repair for extensive aortic aneurysm using the pull-through technique].

We describe 2 cases of extensive aortic aneurysm. One was an 88-year-old female with a diagnosis of a rupture of the distal descending aortic aneurysm and the distal arch aneurysm. The 2nd case was a 68-year-old female who had undergone graft replacement of the ascending aorta for acute type A dissection 5 years before. She was diagnosed with an enlarging aneurysm of the false lumen from the transverse arch to the distal descending aorta. We performed 1 stage replacement of the aortic arch and the descending thoracic aorta by using the pull-through technique with a long elephant trunk (LET) through a median sternotomy under selective cerebral perfusion. Distal anastomosis of LET was done by posterior mediastinal approach. Postoperative courses were uneventful without neurological deterioration or respiratory distress.

Successful reconstructive surgery for isolated mitral insufficiency associated with Williams syndrome: report of a case.

Isolated mitral insufficiency requiring surgical correction is extremely rare in Williams syndrome (WS). We report the case of a 25-year-old man with WS, who suffered congestive heart failure caused by severe mitral insufficiency and atrial fibrillation. We found extensive anterior leaflet prolapse, but no other cardiovascular disorders such as supra-aortic or pulmonary arterial stenosis. He underwent successful radical valve repair with a concomitant Cox-maze procedure. This reconstructive procedure was appropriate and effective surgical treatment for isolated mitral valve disease associated with WS.

Gene transfection of hepatocyte growth factor attenuates the progression of cardiac remodeling in the hypertrophied heart.

OBJECTIVES: Hepatocyte growth factor plays a significant role in angiogenesis, anti-apoptosis, and anti-transforming growth factor-beta1-mediated fibrosis in several organs. In this study, we investigated the effect of transfection of the hepatocyte growth factor gene in attenuation of cardiac remodeling in the hypertrophied heart. METHODS: Two weeks after banding the ascending aorta of male Sprague-Dawley rats, a hemagglutinating virus of Japan-liposome complex with (H group) or without (C group) human hepatocyte growth factor cDNA was transfected into the left ventricle wall by direct injection. The hepatocyte growth factor, c-Met, and transforming growth factor-beta1 mRNA levels in the left ventricle were then analyzed by real-time quantitative reverse-transcriptase polymerase chain reaction. RESULTS: Two weeks after transfection, the expression of transforming growth factor-beta1 mRNA was significantly attenuated in the H group compared with the C group (P < .01). Myocardial collagen content after 4 weeks of banding was significantly lower in the H group (5.0 +/- 0.6 mg/g tissue) than in the C group (7.4 +/- 0.5 mg/g tissue, P < .01). Left ventricular diastolic function (E/A ratios quantified by Doppler echocardiography) showed a significant increase in the H group (1.9 +/- 0.1) compared with the C group (1.1 +/- 0.1, P < .01). CONCLUSIONS: Our results demonstrated that gene transfection of hepatocyte growth factor attenuated left ventricular diastolic dysfunction and cardiac fibrosis in association with a decrease in transforming growth factor-beta1 in the rat heart subjected to pressure overload. Thus, the transfection of the hepatocyte growth factor gene into the hypertrophied heart may be a strategy for the hypertrophied and failing heart even for cardiac surgery.

Influence of coronary artery disease on operative mortality and long-term survival after abdominal aortic aneurysm repair.

PURPOSE: This retrospective study was conducted to evaluate the effects of coronary artery disease (CAD) on short- and long-term survival after abdominal aortic aneurysm (AAA) repair. METHODS: One hundred consecutive patients underwent elective AAA repair between 1991 and 2002. Coronary angiography was performed in all patients, revealing significant coronary artery lesions in 47 (47%). Percutaneous transluminal coronary angioplasty (PTCA) was performed in 11 patients, 20 (median) days before the abdominal surgery. Abdominal aortic aneurysm repair was performed 60 (median) days after coronary artery bypass grafting (CABG) in five patients, and both procedures were performed simultaneously in two patients. RESULTS: The in-hospital mortality rate for AAA repair was 1.0%, but there was no cardiac-related operative morbidity or mortality. The 96 patients discharged were followed up for a mean period of 2.9 years (range 3-143 months). The cumulative survival rates after 1, 2, 3, and 5 years were 98%, 95%, 88%, and 77%, respectively. Only one patient (1%) died of myocardial infarction. There was no significant difference in the long-term survival of the CAD and non-CAD patients. CONCLUSIONS: These results emphasize the importance of routine coronary angiography and subsequent coronary revascularization to improve early and late survival rates after AAA repair.

Gene transfection of hepatocyte growth factor attenuates cardiac remodeling in the canine heart: A novel gene therapy for cardiomyopathy.

OBJECTIVE: Hepatocyte growth factor, a potent angiogenic agent, is unique in having the effects of antiapoptosis and antifibrosis. In the present study we used the rapid pacing-induced heart failure canine model to investigate the effect of gene transfection of hepatocyte growth factor on the failing heart. METHODS: Four weeks after onset of rapid pacing, either the human hepatocyte growth factor gene (160 microg; hepatocyte growth factor group, n = 7) or empty vector (control group, n = 7) was directly injected into the left ventricular myocardium by means of the hemagglutinating virus of Japan liposome method. RESULTS: At 4 weeks after gene transfection, the left ventricular global function, assessed by means of pressure-volume loop analysis, was improved in the hepatocyte growth factor group as preload-recruitable stroke work (percentage of baseline: 80% +/- 20% from 38% +/- 15% before gene transfection, P =.005), whereas it was not changed in the control group (50% +/- 18% from 50% +/- 18%). Weekly echocardiography showed that this improvement began in the week after gene transfer. The hearts in the hepatocyte growth factor group had a large wall thickness, large myocyte diameter, high capillary density, low fibrotic area fraction, and low density of apoptotic nuclei revealed by means of histologic analysis compared with that in the control group. Myocardial perfusion flow, assessed with color microspheres, was increased in the hepatocyte growth factor group (percentage of baseline: 79% +/- 16% from 48% +/- 14%, P =.010), whereas it was reduced in the control group (30% +/- 12% from 45% +/- 17%). CONCLUSIONS: Gene transfection of hepatocyte growth factor promoted angiogenesis, improved perfusion, decreased fibrosis and apoptosis, promoted recovery from myocyte atrophy, and thereby attenuated cardiac remodeling and improved myocardial function in the failing heart. It is a novel gene therapy for human heart failure.