Triggered release from thermosensitive liposomes improves tumor targeting of vinorelbine.

Triggered drug delivery strategies have been shown to enhance drug accumulation at target diseased sites in comparison to administration of free drug. In particular, many studies have demonstrated improved targetability of chemotherapeutics when delivered via thermosensitive liposomes. However, most studies continue to focus on encapsulating doxorubicin while many other drugs would benefit from this targeted and localized delivery approach. The proposed study explores the therapeutic potential of a thermosensitive liposome formulation of the commonly used chemotherapy drug vinorelbine in combination with mild hyperthermia (39-43 °C) in a murine model of rhabdomyosarcoma. Rhabdomyosarcoma, the most common soft tissue sarcoma in children, is largely treated using conventional chemotherapy which is associated with significant adverse long-term sequelae. In this study, mild hyperthermia was pursued as a non-invasive, non-toxic means to improve the efficacy and safety profiles of vinorelbine. Thorough assessment of the pharmacokinetics, biodistribution, efficacy and toxicity of vinorelbine administered in the thermosensitive liposome formulation was compared to administration in a traditional, non-thermosensitive liposome formulation. This study shows the potential of an advanced formulation technology in combination with mild hyperthermia as a means to target an untargeted therapeutic agent and result in a significant improvement in its therapeutic index.

Harnessing immunotherapy to enhance the systemic anti-tumor effects of thermosensitive liposomes.

Chemotherapy plays an important role in debulking tumors in advance of surgery and/or radiotherapy, tackling residual disease, and treating metastatic disease. In recent years many promising advanced drug delivery strategies have emerged that offer more targeted delivery approaches to chemotherapy treatment. For example, thermosensitive liposome-mediated drug delivery in combination with localized mild hyperthermia can increase local drug concentrations resulting in a reduction in systemic toxicity and an improvement in local disease control. However, the majority of solid tumor-associated deaths are due to metastatic spread. A therapeutic approach focused on a localized target area harbors the risk of overlooking and undertreating potential metastatic spread. Previous studies reported systemic, albeit limited, anti-tumor effects following treatment with thermosensitive liposomal chemotherapy and localized mild hyperthermia. This work explores the systemic treatment capabilities of a thermosensitive liposome formulation of the vinca alkaloid vinorelbine in combination with mild hyperthermia in an immunocompetent murine model of rhabdomyosarcoma. This treatment approach was found to be highly effective at heated, primary tumor sites. However, it demonstrated limited anti-tumor effects in secondary, distant tumors. As a result, the addition of immune checkpoint inhibition therapy was pursued to further enhance the systemic anti-tumor effect of this treatment approach. Once combined with immune checkpoint inhibition therapy, a significant improvement in systemic treatment capability was achieved. We believe this is one of the first studies to demonstrate that a triple combination of thermosensitive liposomes, localized mild hyperthermia, and immune checkpoint inhibition therapy can enhance the systemic treatment capabilities of thermosensitive liposomes.

Pneumococcal Surface Protein A-Hybrid Nanoparticles Protect Mice from Lethal Challenge after Mucosal Immunization Targeting the Lungs.

Pneumococcal disease remains a global burden, with current conjugated vaccines offering protection against the common serotype strains. However, there are over 100 serotype strains, and serotype replacement is now being observed, which reduces the effectiveness of the current vaccines. Pneumococcal surface protein A (PspA) has been investigated as a candidate for new serotype-independent pneumococcal vaccines, but requires adjuvants and/or delivery systems to improve protection. Polymeric nanoparticles (NPs) are biocompatible and, besides the antigen, can incorporate mucoadhesive and adjuvant substances such as chitosans, which improve antigen presentation at mucosal surfaces. This work aimed to define the optimal NP formulation to deliver PspA into the lungs and protect mice against lethal challenge. We prepared poly(glycerol-adipate-co-ω-pentadecalactone) (PGA-co-PDL) and poly(lactic-co-glycolic acid) (PLGA) NPs using an emulsion/solvent evaporation method, incorporating chitosan hydrochloride (HCl-CS) or carboxymethyl chitosan (CM-CS) as hybrid NPs with encapsulated or adsorbed PspA. We investigated the physicochemical properties of NPs, together with the PspA integrity and biological activity. Furthermore, their ability to activate dendritic cells in vitro was evaluated, followed by mucosal immunization targeting mouse lungs. PGA-co-PDL/HCl-CS (291 nm) or CM-CS (281 nm) NPs produced smaller sizes compared to PLGA/HCl-CS (310 nm) or CM-CS (299 nm) NPs. Moreover, NPs formulated with HCl-CS possessed a positive charge (PGA-co-PDL +17 mV, PLGA + 13 mV) compared to those formulated with CM-CS (PGA-co-PDL -20 mV, PLGA -40 mV). PspA released from NPs formulated with HCl-CS preserved the integrity and biological activity, but CM-CS affected PspA binding to lactoferrin and antibody recognition. PspA adsorbed in PGA-co-PDL/HCl-CS NPs stimulated CD80+ and CD86+ cells, but this was lower compared to when PspA was encapsulated in PLGA/HCl-CS NPs, which also stimulated CD40+ and MHC II (I-A/I-E)+ cells. Despite no differences in IgG being observed between immunized animals, PGA-co-PDL/HCl-CS/adsorbed-PspA protected 83% of mice after lethal pneumococcal challenge, while 100% of mice immunized with PLGA/HCl-CS/encapsulated-PspA were protected. Therefore, this formulation is a promising vaccine strategy, which has beneficial properties for mucosal immunization and could potentially provide serotype-independent protection.

An Overview of Nanocarrier-Based Adjuvants for Vaccine Delivery.

The development of vaccines is one of the most significant medical accomplishments which has helped to eradicate a large number of diseases. It has undergone an evolutionary process from live attenuated pathogen vaccine to killed whole organisms or inactivated toxins (toxoids), each of them having its own advantages and disadvantages. The crucial parameters in vaccination are the generation of memory response and protection against infection, while an important aspect is the effective delivery of antigen in an intelligent manner to evoke a robust immune response. In this regard, nanotechnology is greatly contributing to developing efficient vaccine adjuvants and delivery systems. These can protect the encapsulated antigen from the host's in-vivo environment and releasing it in a sustained manner to induce a long-lasting immunostimulatory effect. In view of this, the present review article summarizes nanoscale-based adjuvants and delivery vehicles such as viral vectors, virus-like particles and virosomes; non-viral vectors namely nanoemulsions, lipid nanocarriers, biodegradable and non-degradable nanoparticles, calcium phosphate nanoparticles, colloidally stable nanoparticles, proteosomes; and pattern recognition receptors covering c-type lectin receptors and toll-like receptors.

In Vitro Characterization of Inhalable Cationic Hybrid Nanoparticles as Potential Vaccine Carriers.

In this study, PGA-co-PDL nanoparticles (NPs) encapsulating model antigen, bovine serum albumin (BSA), were prepared via double emulsion solvent evaporation. In addition, chitosan hydrochloride (CHL) was incorporated into the external phase of the emulsion solvent method, which resulted in surface adsorption onto the NPs to form hybrid cationic CHL NPs. The BSA encapsulated CHL NPs were encompassed into nanocomposite microcarriers (NCMPs) composed of l-leucine to produce CHL NPs/NCMPs via spray drying. The CHL NPs/NCMPs were investigated for in vitro aerosolization, release study, cell viability and uptake, and stability of protein structure. Hybrid cationic CHL NPs (CHL: 10 mg/mL) of particle size (480.2 ± 32.2 nm), charge (+14.2 ± 0.72 mV), and BSA loading (7.28 ± 1.3 µg/mg) were produced. The adsorption pattern was determined to follow the Freundlich model. Aerosolization of CHL NPs/NCMPs indicated fine particle fraction (FPF: 46.79 ± 11.21%) and mass median aerodynamic diameter (MMAD: 1.49 ± 0.29 µm). The BSA α-helical structure was maintained, after release from the CHL NPs/NCMPs, as indicated by circular dichroism. Furthermore, dendritic cells (DCs) and A549 cells showed good viability (≥70% at 2.5 mg/mL after 4-24 h exposure, respectively). Confocal microscopy and flow cytometry data showed hybrid cationic CHL NPs were successfully taken up by DCs within 1 h of incubation. The upregulation of CD40, CD86, and MHC-II cell surface markers indicated that the DCs were successfully activated by the hybrid cationic CHL NPs. These results suggest that the CHL NPs/NCMPs technology platform could potentially be used for the delivery of proteins to the lungs for immunostimulatory applications such as vaccines.

Evaluation of polymer choice on immunogenicity of chitosan coated PLGA NPs with surface-adsorbed pneumococcal protein antigen PspA4Pro.

Polymeric nanoparticles (NPs) are recognized as potential delivery vehicles for vaccines. PLGA is a biocompatible polymer synonymous with polymeric NPs, which can be coated with other polymers such as chitosan that has intrinsic adjuvant properties as well as mucoadhesive properties. Numerous modifications and variations exist for PLGA and chitosan, which can influence the NP characteristics and the resulting immunogenicity. The current study investigated variations for making chitosan coated PLGA NPs incorporating recombinant pneumococcal surface protein A from family 2, clade 4 (PspA4Pro) antigen as a vaccine targeting the vast majority of pneumococcal strains and determine the effect of the polymers on particle size, surface charge, and surface marker upregulation on a dendritic cell (DC) line in vitro. PLGA variations tested with the ester-terminal group had the greatest detriment for prospective vaccine use, due to the lowest PspA4Pro adsorption and induction of CD40 and CD86 cell surface markers on DCs. The negatively charged chitosans exhibited the lowest surface marker expressions, similar to the uncoated NP, supporting the commonly accepted notion that positive surface charge augments immunogenic effects of the NPs. However, the study indicated that NPs made from PLGA with an acid terminated group, and chitosan HCl salt, exhibit particle characteristics, antigen adsorption efficiency and immunogenicity, which could be most suitable as a vaccine formulation.

Progress in mucosal immunization for protection against pneumococcal pneumonia.

Introduction: Lower respiratory tract infections are the fourth cause of death worldwide and pneumococcus is the leading cause of pneumonia. Nonetheless, existing pneumococcal vaccines are less effective against pneumonia than invasive diseases and serotype replacement is a major concern. Protein antigens could induce serotype-independent protection, and mucosal immunization could offer local and systemic immune responses and induce protection against pneumococcal colonization and lung infection. Areas covered: Immunity induced in the experimental human pneumococcal carriage model, approaches to address the physiological barriers to mucosal immunization and improve delivery of the vaccine antigens, different strategies already tested for pneumococcal mucosal vaccination, including live recombinant bacteria, nanoparticles, bacterium-like particles, and nanogels as well as, nasal, pulmonary, sublingual and oral routes of vaccination. Expert opinion: The most promising delivery systems are based on nanoparticles, bacterial-like particles or nanogels, which possess greater immunogenicity than the antigen alone and are considered safer than approaches based on living cells or toxoids. These particles can protect the antigen from degradation, eliminating the refrigeration need during storage and allowing the manufacture of dry powder formulations. They can also increase antigen uptake, control release of antigen and trigger innate immune responses.

Carriers for the targeted delivery of aerosolized macromolecules for pulmonary pathologies.

INTRODUCTION: Macromolecules with unique effects and potency are increasingly being considered for application in lung pathologies. Numerous delivery strategies for these macromolecules through the lung have been investigated to improve the targeting and overall efficacy. AREAS COVERED: Targeting approaches from delivery devices, formulation strategies and specific targets are discussed. EXPERT OPINION: Although macromolecules are a heterogeneous group of molecules, a number of strategies have been investigated at the macro, micro, and nanoscopic scale for the delivery of macromolecules to specific sites and cells of lung tissues. Targeted approaches are already in use at the macroscopic scale through inhalation devices and formulations, but targeting strategies at the micro and nanoscopic scale are still in the laboratory stage. The combination of controlling lung deposition and targeting after deposition, through a combination of targeting strategies could be the future direction for the treatment of lung pathologies through the pulmonary route.

Characterization and evaluation of stabilized particulate formulations as therapeutic oral vaccines for allergy.

Allergic conditions affect more than a quarter of the population in developed countries, but currently available treatments focus more on symptom relief than treating the underlying atopic condition. α-Galactosylceramide (α-GalCer) is a potent immunomodulating compound that has been shown to have a regulatory effect when delivered systemically in nanoparticles. Parenteral delivery is not preferred for chronic conditions, such as allergy, and therefore, the aim of this study was to determine whether a regulatory response could be induced through oral administration in a model of atopy through incorporation of α-GalCer into stable particulate formulations (cationic liposomes, polymerized liposomes and poly(lactic-co-glycolic acid) nanoparticles (PLGA NPs)). The formulations showed only minor changes in particle size, polydispersity index and retention of the model antigen ovalbumin (OVA) during incubation in simulated gastrointestinal (GI) conditions. Oral delivery of α-GalCer in cationic liposomes could induce immunostimulating effects systemically, as seen through increases in serum IgG antibody levels, whereas delivery of α-GalCer in polymerized liposomes and PLGA NPs induced local cytokine changes in the mesenteric lymph nodes (MLNs). The generated responses did not exhibit tolerogenic traits which could be useful for immunoregulation, but the responses generated varied between formulations and suggests that further characterization and optimization could lead to the desired immune response.

Liposomal α-galactosylceramide is taken up by gut-associated lymphoid tissue and stimulates local and systemic immune responses.

OBJECTIVES: α-Galactosylceramide (α-GalCer), a synthetic glycosphingolipid that exhibits potent immunostimulatory effects through activation of natural killer T (NKT) cells, can be used to treat conditions such as atopy, cancer, infection and autoimmunity. Administration of therapeutics through the oral route has advantages such as patient convenience, safety and reduced cost; however, there has been little research to investigate whether oral delivery of α-GalCer is possible. The aim of this study was therefore to determine whether α-GalCer formulated in either DMSO/Tween 80 or in liposomes, could access lymphoid tissue and stimulate immune activation following oral administration. METHODS: Fluorescently labelled cationic liposomes incorporating α-GalCer were prepared, characterized and administered by oral gavage to fasted mice. KEY FINDINGS: Liposomes were detected inside the Peyer's patches (PPs), in the subepithelial dome just under the follicle-associated epithelium. CD11b+ cells and CD11c+ were shown to have taken up the formulation in a higher proportion compared to the total cell proportion in the PPs, suggesting that cells with these markers may be the prominent antigen-presenting cells involved in selective uptake. Finally, the liposomal formulation demonstrated a higher degree of immune stimulation compared to the DMSO/Tween 80 solubilized α-GalCer in the PPs, mesenteric lymph nodes and spleen as shown by the increased expression of IL-4 mRNA expression and increased proportion of NKT cells at 6 h and 3 days after administration. CONCLUSIONS: These results show that oral delivery of a liposomal α-GalCer can stimulate local and systemic immune responses to a different degree compared to the non-liposomal form.

Vaccination of Sheep with a Methanogen Protein Provides Insight into Levels of Antibody in Saliva Needed to Target Ruminal Methanogens.

Methane is produced in the rumen of ruminant livestock by methanogens and is a major contributor to agricultural greenhouse gases. Vaccination against ruminal methanogens could reduce methane emissions by inducing antibodies in saliva which enter the rumen and impair ability of methanogens to produce methane. Presently, it is not known if vaccination can induce sufficient amounts of antibody in the saliva to target methanogen populations in the rumen and little is known about how long antibody in the rumen remains active. In the current study, sheep were vaccinated twice at a 3-week interval with a model methanogen antigen, recombinant glycosyl transferase protein (rGT2) formulated with one of four adjuvants: saponin, Montanide ISA61, a chitosan thermogel, or a lipid nanoparticle/cationic liposome adjuvant (n = 6/formulation). A control group of sheep (n = 6) was not vaccinated. The highest antigen-specific IgA and IgG responses in both saliva and serum were observed with Montanide ISA61, which promoted levels of salivary antibodies that were five-fold higher than the second most potent adjuvant, saponin. A rGT2-specific IgG standard was used to determine the level of rGT2-specific IgG in serum and saliva. Vaccination with GT2/Montanide ISA61 produced a peak antibody concentration of 7 × 1016 molecules of antigen-specific IgG per litre of saliva, and it was estimated that in the rumen there would be more than 104 molecules of antigen-specific IgG for each methanogen cell. Both IgG and IgA in saliva were shown to be relatively stable in the rumen. Salivary antibody exposed for 1-2 hours to an in vitro simulated rumen environment retained approximately 50% of antigen-binding activity. Collectively, the results from measuring antibody levels and stablility suggest a vaccination-based mitigation strategy for livestock generated methane is in theory feasible.

Prospective study of superior cluneal nerve disorder as a potential cause of low back pain and leg symptoms.

BACKGROUND: Entrapment of the superior cluneal nerve (SCN) in an osteofibrous tunnel has been reported as a cause of low back pain (LBP). However, there are few reports on the prevalence of SCN disorder and there are several reports only on favorable outcomes of treatment of SCN disorder on LBP. The purposes of this prospective study were to investigate the prevalence of SCN disorder and to characterize clinical manifestations of this clinical entity. METHODS: A total of 834 patients suffering from LBP and/or leg symptoms were enrolled in this study. Diagnostic criteria for suspected SCN disorder were that the maximally tender point was on the posterior iliac crest 70 mm from the midline and that palpation of the tender point reproduced the chief complaint. When patients met both criteria, a nerve block injection was performed. At the initial evaluation, LBP and leg symptoms were assessed by visual analog scale (VAS) score. At 15 min and 1 week after the injection, VAS pain levels were recorded. If insufficient pain decrease or recurrence of pain was observed, injections were repeated weekly up to three times. Surgery was done under microscopy. Operative findings of the SCN and outcomes were recorded. RESULTS: Of the 834 patients, 113 (14%) met the criteria and were given nerve block injections. Of these, 54 (49%) had leg symptoms. Before injection, the mean VAS score was 68.6 ± 19.2 mm. At 1 week after injection, the mean VAS score significantly decreased to 45.2 ± 28.8 mm (p < 0.05). Ninety-six of the 113 patients (85%) experienced more than a 20 mm decrease of the VAS score following three injections and 77 patients (68%) experienced more than a 50% decrease in the VAS score. Surgery was performed in 19 patients who had intractable symptoms. Complete and almost complete relief of leg symptoms were obtained in five of these surgical patients. CONCLUSIONS: SCN disorder is not a rare clinical entity and should be considered as a cause of chronic LBP or leg pain. Approximately 50% of SCN disorder patients had leg symptoms.

Histopathological examination by lung biopsy for the evaluation of operability and postoperative prognosis in patients with chronic thromboembolic pulmonary hypertension.

BACKGROUND: To evaluate the prognosis after pulmonary thromboendarterectomy (PTE) in patients with chronic thromboembolic pulmonary hypertension (CTEPH), a lung biopsy was performed in 34 patients with central CTEPH and in 7 patients with peripheral CTEPH during PTE. METHODS AND RESULTS: Postoperative prognosis was classified from A to E based on the postoperative hemodynamic parameters and clinical condition, and was compared with the index of occlusion (IOCTEPH), which indicates the degree of occlusion in the small pulmonary arteries. Criteria of (A-E) were established only for central CTEPH. Category (A) corresponded to an IOCTEPH from 1.0 to 1.4, (B) from 1.5 to 1.7, (C) from 1.8 to 2.0, and (D) from 2.1 to 2.4. One patient with an index of 3.0 was rated as (E). This patient had collateral vessels around the obstructed small pulmonary arteries and died postoperatively. In all 12 patients who underwent PTE after the criteria were established, postoperative hemodynamic parameters and clinical conditions were consistent with the IOCTEPH. One patient with a high degree of medial atrophy in their small pulmonary arteries died after PTE. CONCLUSIONS: These results indicate that a lung biopsy during PTE is useful for prognostication in patients with CTEPH.

Respiratory and hemodynamic changes in patients with chronic thromboembolic pulmonary hypertension 1 year after pulmonary endarterectomy.

We reviewed the results of thromboembolectomy, which was performed for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), 1 year after the operation. We obtained hemodynamic and respiratory data of 60 patients from the 112 patients who were operated at our institute. The hemodynamic parameters such as mean pulmonary arterial pressure (PAP), pulmonary vascular resistance (PVR), and cardiac index (CI) were significantly improved after the operation, and this improvement of pulmonary hemodynamics persisted even a year after the operation. A significant improvement in gas exchange was observed immediately after the operation and a further elevation in the partial pressure of oxygen in arterial blood (PaO2) was observed 1 year after the operation. (English Translation of J Jpn Coll Angiol 2012; 52: 53-58).

Arch replacement using antegrade selective cerebral perfusion for shaggy aorta.

BACKGROUND: Embolic stroke during arch replacement is a serious concern in patients with shaggy aorta. OBJECTIVE: To evaluate shaggy aorta in patients who received total aortic arch replacement with antegrade selective cerebral perfusion utilizing axillary perfusion. METHOD: Between January 2005 and December 2010, 63 patients underwent preoperative contrast-enhanced computed tomography scanning of the aorta to evaluate atheromatous plaque. We analyzed operative data to investigate which factors were associated with outcomes and survival. RESULTS: Shaggy aorta was found in 34 (54%) patients. There were 3 (5%) cases in the ascending aorta, 26 (41%) in the aortic arch, and 19 (30%) in the descending aorta. Operative mortality occurred in 1 (2%) patient. Although stroke occurred in 2 (3%) shaggy aorta patients, shaggy aorta was not associated with an increased likelihood of stroke (p = 0.4951). Survival was significantly lower in patients with shaggy descending aorta (p = 0.0411) and in patients >75-years old (p = 0.0200); these traits were identified as independent risk factors for late death (p = 0.0368 and p = 0.0100, respectively). CONCLUSION: We concluded that our perfusion technique protects patients with shaggy aorta against embolism, and that the survival is lower in patients with shaggy descending aorta.

Excellent durability of Starr-Edwards ball valves implanted in the aortic and mitral positions for 27 years: report of a rare surgical case.

A 59-year-old male who had undergone aortic and mitral valve replacement with Starr-Edwards ball valves 27 years ago was admitted to our hospital for hemolytic anemia and heart failure. Echocardiography revealed prosthetic valve failure with a high-pressure gradient and small effective orifice area. The Starr-Edwards ball valves were successfully replaced with bileaflet mechanical valves. The explanted valves revealed no structural abnormalities.

Non-invasive evaluation of internal thoracic artery anastomosed to the left anterior descending artery with 320-detector row computed tomography and adenosine thallium-201 myocardial perfusion scintigraphy.

PURPOSE: We evaluated the relationship between internal thoracic artery (ITA) stenosis anastomosed to the left anterior descending artery (LAD) and the degree of LAD stenosis using 320-detector row computed tomography (320-ADCT) and adenosine thallium-201 myocardial perfusion scintigraphy (Tl-201-MPS). METHODS: We included 101 patients who underwent coronary artery bypass grafting (CABG) using ITA grafts; 320-ADCT and adenosine Tl-201-MPS were performed 2-3 months after CABG. Clinical parameters, degree of LAD stenosis, and regional myocardial ischemia of the LAD territory were compared between patients without ITA stenosis (Group A) and with ITA stenosis (Group B). RESULTS: Thirty patients (30%) had ≤75% LAD stenosis, and 9 patients (30%) showed significant ITA stenosis. Regional ischemia was noted in 23 patients (23%). There were no differences in clinical parameters between the 2 groups. Twenty-two patients (24%) in Group A and 8 patients (89%) in Group B had ≤75% LAD stenosis (P <0.002). No Group B patients had regional myocardial ischemia of the LAD territory. CONCLUSION: We concluded that ≤75% LAD stenosis significantly influences ITA stenosis, without associated regional myocardial ischemia of the LAD territory. Non-invasive 320-ADCT and adenosine Tl-201-MPS for ITA evaluation may be useful for long-term follow-up of patients after CABG.

The importance of preoperative magnetic resonance imaging in valve surgery for active infective endocarditis.

PURPOSE: Valve surgery for active infective endocarditis (IE) can cause fatal brain hemorrhage. Our current study aimed to evaluate the incidence of septic cerebral lesions in active IE patients by performing preoperative magnetic resonance imaging (MRI) including T(2)*- weighted sequences and magnetic resonance angiography (MRA) before urgent valve surgery, and to investigate whether such preoperative evaluation affects postoperative outcomes. METHODS: Eighteen patients were referred to our department for native valve IE during 2006-2010. Urgent surgery was indicated in cases of hemodynamic failure resulting from valve destruction, refractory sepsis, and mobile vegetations measuring >10 mm. For these patients, we performed preoperative MRI and MRA. RESULTS: Males comprised 67% of the subjects, with average age 53 ± 15 years. No clinical evidence of acute stroke was noted. Of the 18 patients, urgent surgery was indicated in 15; of these, 10 (67%) showed a brain lesion related to IE: 6 patients had acute or subacute brain infarctions, 2 patients had brain infarction with brain abscess, and 2 patients had hemorrhagic brain infarction and so did not undergo urgent surgery. Thus, 13 patients underwent urgent valve surgery. Among the 5 patients who did not undergo urgent surgery, 4 patients later underwent valve surgery for healed IE. No hospital deaths or neurological complications occurred. CONCLUSION: MRI of patients with active IE revealed a high incidence of cerebral lesions caused by IE. The use of MRI to detect septic embolism and intracerebral hemorrhage may provide important information for better surgical outcomes.

Pseudoaneurysm of ascending aorta 16 years after coronary artery bypass grafting.

Pseudoaneurysm of the ascending aorta after cardiac surgery is a rare but life threatening complication, which can result in rupture. Pseudoaneurysms are usually related to the aortic cannulation, the proximal site of graft anastomosis, or the suture line of aortotomy, and often occur after mediastinal infection. We report a case of pseudoaneurysm of the ascending aorta associated with aortic cannulation and the proximal anastomosis of a saphenous vein graft without an obvious history of mediastinal infection.

Iatrogenic type A aortic dissection after catheter intervention for the left subclavian artery.

Cardiac surgical procedure and catheter intervention of the aorta or its major branches have a potential risk for iatrogenic aortic dissection. This case demonstrates an iatrogenic type A aortic dissection after the elective balloon angioplasty for severe stenosis of the left subclavian artery orifice. The dissection retrospectively extended to the ascending aorta, and intramural hematoma was observed in the false lumen of the aorta. The ascending aorta was successfully replaced 14 days after the occurrence of dissection, using hypothermic circulatory arrest and antegrade selective cerebral perfusion. There were no outstanding complications.