Successful conservative management of advanced pyogenic sternoclavicular joint arthritis with osteomyelitis and pulmonary infiltration: a case report.

BACKGROUND: Sternoclavicular joint arthritis is a rare condition that poses considerable diagnostic and therapeutic challenges, leading to severe complications and a high mortality rate. Although surgical interventions are often considered necessary for advanced cases, some reports have suggested that conservative management with antibiotic therapy can be effective in certain cases. However, to our knowledge, there are no reports of successful conservative treatment in cases exhibiting aggressive spread. This report highlights a case of advanced sternoclavicular joint arthritis with bone destruction and pulmonary infiltration, successfully treated conservatively with outpatient antibiotic therapy. CASE PRESENTATION: A 58-year-old Japanese male presented with a 1-month history of left-sided shoulder pain. Contrast-enhanced computed tomography showed abscess formation and clavicular bone destruction, with infiltrative shadows suggesting lung involvement. The diagnosis of sternoclavicular joint arthritis was made, and outpatient oral antibiotic therapy was initiated. The patient exhibited a marked reduction in inflammatory marker levels and symptoms, and antibiotic therapy was discontinued after 3 weeks, with no recurrence observed at a 4-month follow-up. CONCLUSIONS: This case highlights that conservative management with antibiotics can be effective for treating advanced sternoclavicular joint arthritis, emphasizing the need for individualized management and further research into non-surgical treatment options.

Clinical efficacy of TEVAR utilizing fenestrated stent-grafts for zone 0 in an elderly frail patient with giant aortic arch aneurysm.

Introduction and importance: Elderly and frail patients with thoracic aortic aneurysms (TAAs) near to origins of cervical arteries present facing challenges with aortic arch replacement with cardiopulmonary bypass, and traditional tube-type stent-grafts are also inadequate for transcatheter endovascular aortic repair (TEVAR). Thus, necessitating precise treatment with fenestrated stent-grafts from zone 0. This approach is crucial for achieving favorable postoperative outcomes without compromising activities of daily living (ADL). Case presentations: An 85-year-old-man admitted to the hospital for treatment of a large TAA. While arch replacement is a definitive procedure, it is highly invasive, and the postoperative ADL are expected to be significantly lower than preoperative levels. Therefore, we performed a debranching TEVAR from Zone 0 with fenestrated stent-graft. The patient was discharged from the hospital on the 11th postoperative day. Clinical discussion: In frail and elderly patients for whom conventional surgery may not be viable, TEVAR emerges as a preferred alternative. However, TEVAR of TAA proximal to the aortic arch continues to pose challenges, necessitating meticulous attention to the cervical branches in the intervention strategy. While surgical intervention in these patients necessitates careful consideration of its suitability, including the potential for postoperative enhancement in ADL, the use of fenestrated stent-grafts from Zone 0 emerges as one of the treatment modalities. Conclusion: The authors present a very elderly case in which fenestrated stent-grafts were used to avoid aortic arch replacement for a large aortic arch aneurysm, resulting in a good postoperative course with no decline in ADL.

Acute Lymphocytic Myocarditis With Mobile Left Ventricular Thrombus.

A left ventricular thrombus (LVT) in cardiac disease is associated with various adverse events. To understand the risk of thromboembolism, it is necessary to recognize when LVT is most likely to occur. We present a case of acute lymphocytic myocarditis in a young patient, where the LVT manifestation occurred within 48 hours after the beginning of the disease and was treated by thrombectomy. We have not found any reports of LVT formation earlier than in this case. Patients with acute myocarditis are younger, at a median age of 34 years, and the social impact of embolic complications is considerable. Echocardiography is effective in detecting LVT noninvasively in low- and high-risk patients. Patients with myocarditis can benefit from careful observation by echocardiography.

Bioprosthetic Valve Deterioration: Accumulation of Circulating Proteins and Macrophages in the Valve Interstitium.

Histologic evaluations revealed excessive accumulations of macrophages and absence of fibroblastic interstitial cells in explanted bioprosthetic valves. Comprehensive gene and protein expression analysis and histology unveiled an accumulation of fibrinogen and plasminogen, an activator of infiltrated macrophages, from degenerated valve surfaces in the interstitial spaces. These pathologies were completely reproduced in a goat model replaced with an autologous pericardium-derived aortic valve. Further preclinical animal experiments using goats demonstrated that preventing infiltration of macrophages and circulating proteins by increasing collagen density and leaflet strength is an effective treatment option.

Is the QRS duration useful for determining the optimal timing of pulmonary valve replacement after tetralogy of Fallot repair?

OBJECTIVES: In pulmonary valve replacement (PVR) after tetralogy of Fallot (TOF) repair, the right ventricular end-diastolic and end-systolic volume index (RVEDVI and RVESVI) of cardiac magnetic resonance imaging (cMRI) are often used as indicators of the RV volume. We examined the utility of QRS duration, cardiothoracic ratio (CTR), and plasma brain natriuretic peptide (BNP) as indicators of the appropriate timing of cMRI to assess the RV volume and function before PVR. METHODS: We assessed the correlation of QRS duration, CTR, and BNP with RVEDVI and RVESVI on cMRI in 26 patients after TOF repair. Fifteen underwent PVR (age, 45.2 ± 11.4 years). Twelve underwent post-PVR cMRI. The RV volume change from before to after PVR was investigated. RESULTS: QRS duration, BNP, and CTR were positively correlated with RVEDVI and RVESVI after TOF repair. The post-PVR QRS duration was also positively correlated with post-PVR RVEDVI (p = 0.017) and RVESVI (p = 0.001). From before to after PVR, in 5 cases with QRS duration ≤ 160 ms, the QRS duration decreased from 110.4 ± 28.9 to 101.8 ± 30.5 ms (p = 0.063). Both RVEDVI and RVESVI decreased to the normal range in 4 of 5 cases. In contrast, in 7 cases with QRS duration > 160 ms, the QRS duration decreased from 183.0 ± 17.4 to 160.3 ± 23.8 ms (p = 0.013); however, RVESVI did not normalize in 6 of 7 cases. CONCLUSIONS: A prolonged QRS duration is a useful marker of RVEDVI and RVESVI enlargement after TOF repair. We recommend performing cMRI before the QRS duration reaches 160 ms due to normalization of the RV volume after PVR.

[Active Utilization of Robot-assisted Cardiac Surgery in Educational Institution].

Minimally invasive cardiac surgery( MICS) has emerged in 1990s. Nowadays, MICS via mini thoracotomy became popular for valvular heart disease. Robot-assisted cardiac surgery was introduced with extension to MICS. Robot-assisted cardiac surgery for valvular heart disease has been covered by health insurance since 2018. So far, the number of authorized facilities for robot-assisted cardiac surgery is only 25. Currently available da Vinci surgical system is a burden to not only the surgical team but also the facility. There are a lot of problems to overcome for applying robot-assisted cardiac surgery as a standardized procedure. An educational institution like a university hospital needs to expand systematic human resource development and technological innovation for continuing and developing the robot-assisted cardiac surgery. The most important thing for the surgeon is to keep in mind for true minimally invasive surgery for the patients not for minimally incisional surgery for the cosmetic reason.

Mediastinal and Hilar Lymph Node Metastases from Renal Cell Carcinoma with Concomitant Lung Carcinoma: A Rare Case with Unique Diagnostic Challenges.

A 75-year-old man presented to our hospital 1 year after partial renal resection for clear cell carcinoma. A right lower lobe lung nodule noted at the time of surgery had increased to 3.0 cm in diameter and was confirmed as squamous cell lung carcinoma by bronchoscopic cytology. Computed tomography had also revealed paratracheal lymph node swelling. He underwent right lower lobectomy with lymph node dissection by video-assisted thoracic surgery. Pathological examination confirmed squamous cell carcinoma of the lung but diagnosed the right hilar and mediastinal lymph node metastases as clear cell carcinoma.

Contemporary patterns of the management of truncus arteriosus (primary versus staged repair): outcomes from the Japanese National Cardiovascular Database.

OBJECTIVES: Although primary repair in early infancy has for decades been the prevalent strategy for management of truncus arteriosus (TA), recent concerns about the levels of morbidity and mortality have led to consideration of a staged surgical approach. Our goal was to describe recent patterns of management, to characterize patients who underwent primary or staged repair and to evaluate risk factors associated with operative mortality in a contemporary multicentre cohort. METHODS: In the Japanese Cardiovascular Surgery Database, we identified all cases of TA undergoing an initial surgical procedure from 2008 to 2018. Operative mortality was defined as death within 30 days of an operation or in-hospital death regardless of the length of hospital stay. The hospital volume was defined by the average volume of TA repairs per year. RESULTS: The total number of patients undergoing initial surgery for TA was 286. Sixty-eight (24%, 68/286) underwent primary repair (primary repair group). The remaining 218 (76%, 218/286) underwent initial bilateral pulmonary artery banding as part of a planned staged approach (staged repair group). One hundred sixty-two patients out of 218 initially banded patients underwent the repair of TA during this study period. Concomitant diagnoses in the entire cohort included interrupted aortic arch repair in 36 patients and truncal valve regurgitation in 32. No centres handling an average of ≥2 truncus cases/year of the repair of TA were identified in this cohort. A total of 30% (85/286) of the cases were performed at centres that handled an average of ≥1 and <2 cases/year. The remaining 70% were at centres with <1 case/year. Overall, 37 patients (12.9%; 37/286) died. The operative mortality rates in the primary and staged repair groups were similar: that for the primary repair group was 16.2% (11/68) versus 11.9% for the staged repair group (26/218; P = 0.41). With multivariable logistic regression analysis, the factors most strongly associated with operative mortality were preoperative heart failure requiring catecholamine support (odds ratio, 4.18; 95% confidence interval 1.96-8.96) and the repeat bilateral pulmonary artery banding (odds ratio, 3.89; 95% confidence interval 1.08-14.07). CONCLUSIONS: The staged repair of TA has emerged as the preferred option for surgical timing at most of the centres participating in the Japanese Cardiovascular Surgery Database. The management outcomes of the patients with TA were favourable, even for the patients at low-volume centres.

Use of uniportal video-assisted thoracic surgery combined with a posterior approach to resect a dumbbell-shaped mediastinal granular cell tumor: A case report.

INTRODUCTION: A dumbbell-shaped mediastinal granular cell tumor has never been reported, and there have been no reports of dumbbell-shaped tumors resected with a combination of uniportal video-assisted thoracic surgery and the posterior approach. PRESENTATION OF CASE: An 18-year-old woman was diagnosed with a mediastinal dumbbell-shaped granular cell tumor by computed tomography. Complete resection was achieved via a posterior approach combined with the uniportal video-assisted thoracic surgery. First, a T3 left hemilaminectomy was performed in the prone position and the tumor located inside the intervertebral foramen was removed as far as possible. Next, the patient was repositioned to the right lateral decubitus position, a 2.5-cm skin incision was made on the 4th intercostal posterior axillary line, and resection of the residual tumor was performed. Pathological diagnosis of the resected tumor revealed a benign granular cell tumor. The patient recovered post-surgery and no tumor was reported in the 4-month follow-up magnetic resonance imaging. DISCUSSION: This is the first reported case of a mediastinal dumbbell-shaped granular cell tumor and its successful resection using a combined posterior and uniportal video-assisted thoracic surgery approach. CONCLUSION: This is a potentially safe and effective procedure for mediastinal granular cell tumors, with outstanding cosmetic advantages.

Hypoxic Culture Maintains Cell Growth of the Primary Human Valve Interstitial Cells with Stemness.

The characterization of aortic valve interstitial cells (VICs) cultured under optimal conditions is essential for understanding the molecular mechanisms underlying aortic valve stenosis. Here, we propose 2% hypoxia as an optimum VIC culture condition. Leaflets harvested from patients with aortic valve regurgitation were digested using collagenase and VICs were cultured under the 2% hypoxic condition. A significant increase in VIC growth was observed in 2% hypoxia (hypo-VICs), compared to normoxia (normo-VICs). RNA-sequencing revealed that downregulation of oxidative stress-marker genes (such as superoxide dismutase) and upregulation of cell cycle accelerators (such as cyclins) occurred in hypo-VICs. Accumulation of reactive oxygen species was observed in normo-VICs, indicating that low oxygen tension can avoid oxidative stress with cell-cycle arrest. Further mRNA quantifications revealed significant upregulation of several mesenchymal and hematopoietic progenitor markers, including CD34, in hypo-VICs. The stemness of hypo-VICs was confirmed using osteoblast differentiation assays, indicating that hypoxic culture is beneficial for maintaining growth and stemness, as well as for avoiding senescence via oxidative stress. The availability of hypoxic culture was also demonstrated in the molecular screening using proteomics. Therefore, hypoxic culture can be helpful for the identification of therapeutic targets and the evaluation of VIC molecular functions in vitro.

Quality of life after partial lung resection with uniportal versus 3-port video-assisted thoracoscopic surgery: a prospective randomized controlled study.

PURPOSE: The effect of uniportal video-assisted thoracoscopic surgery (uni-VATS) versus that of conventional VATS on postoperative quality of life (QOL) is unclear. This prospective randomized controlled study compared uni-VATS and conventional 3-port VATS in terms of QOL and patient satisfaction. METHODS: The subjects of this study were 84 patients with pulmonary nodules or bullous formation, randomized to undergo uniportal or conventional 3-port video-assisted thoracoscopic partial lung resection. The primary endpoint was postoperative pain, assessed using a numeric rating scale on postoperative day (POD) 1. RESULTS: No differences were found in the numeric rating scale on POD 1 after uni-VATS and conventional 3-port VATS. There were also no differences in blood loss, operative time, complication rate, surgical margin, analgesic requirement, vital capacity (VC), forced expiratory volume in 1 s (FEV1), the 6-min walk test (6MWT), C-reactive protein (CRP) levels, white blood cell count (WBC), or duration of chest tube drainage and hospital stay. Differences were found in the numeric rating scale on days 2, 3, 5, and 10 and in the patient satisfaction score on PODs 5 and 10. CONCLUSIONS: Uni-VATS is associated with less chest pain and better patient satisfaction in the short term but without differences in complication rates or surgical margins from the lesions. CLINICAL TRIAL REGISTRY NUMBER: University Hospital Medical Information Network Clinical Trial Registry (UMIN000015340 http://www.umin.ac.jp/english/ ).

Unique Angiogenesis From Cardiac Arterioles During Pericardial Adhesion Formation.

OBJECTIVES: The molecular mechanisms underlying post-operative pericardial adhesions remain poorly understood. We aimed to unveil the temporal molecular and cellular mechanisms underlying tissue dynamics during adhesion formation, including inflammation, angiogenesis, and fibrosis. METHODS AND RESULTS: We visualized cell-based tissue dynamics during pericardial adhesion using histological evaluations. To determine the molecular mechanism, RNA-seq was performed. Chemical inhibitors were administered to confirm the molecular mechanism underlying adhesion formation. A high degree of adhesion formation was observed during the stages in which collagen production was promoted. Histological analyses showed that arterioles excessively sprouted from pericardial tissues after the accumulation of neutrophils on the heart surface in mice as well as humans. The combination of RNA-seq and histological analyses revealed that hyperproliferative endothelial and smooth muscle cells with dedifferentiation appeared in cytokine-exposed sprouting vessels and adhesion tissue but not in quiescent vessels in the heart. SMAD2/3 and ERK activation was observed in sprouting vessels. The simultaneous abrogation of PI3K/ERK or TGF-ß/MMP9 signaling significantly decreased angiogenic sprouting, followed by inhibition of adhesion formation. Depleting MMP9-positive neutrophils shortened mice survival and decreased angiogenic sprouting and fibrosis in the adhesion. Our data suggest that TGF-ß/matrix metalloproteinase-dependent tissue remodeling and PI3K/ERK signaling activation might contribute to unique angiogenesis with dedifferentiation of vascular smooth muscle cells from the contractile to the synthetic phenotype for fibrosis in the pericardial cavity. CONCLUSIONS: Our findings provide new insights in developing prevention strategies for pericardial adhesions by targeting the recruitment of vascular cells from heart tissues.