Successful resection of a massive mediastinal liposarcoma that rapidly extended into the entire left thoracic cavity: report of a case.

Primary mediastinal liposarcomas are rare malignancies, comprising fewer than 1% of all mediastinal tumors. We herein report a radical resection of a massive liposarcoma arising from the anterior mediastinum. A 63-year-old male patient presented with a 4-week history of dyspnea that had worsened over the previous several days. The patient had also experienced hoarseness for 2 weeks. Chest X-ray and computed tomography revealed a huge tumor occupying the entire left thoracic cavity. Anesthesia was induced when the patient was in the left semilateral position. The patient was moved into the right lateral position after initially stabilizing anesthesia with separate lung ventilation. The fourth rib was initially resected for thoracotomy, but there was no clearance between the tumor and the adjacent mediastinal structures, and two more ribs were therefore removed. The tumor had not invaded the other structures such as the chest wall, lung, or mediastinum. To reduce the tumor blood flow, the left internal mammary artery was ligated before the tumor was resected en bloc. The tumor was diagnosed as a liposarcoma arising from the thymus. The patient remains alive with no evidence of disease recurrence at 22 months after the operation.

Transient ischemia-induced paresis and complete paraplegia displayed distinct reactions of microglia and macrophages.

In this study, we perform a detailed analysis of the microglial and macrophage responses in a model of spinal cord ischemia and reperfusion (SCI/R) injury in Wistar rats. The rats underwent occlusion across the descending aorta for 13min, causing paraplegia or paresis of varying severity. They were divided into four groups based on neurological assessment: sham, mild paresis, moderate paresis, and severe (complete) paraplegia. To examine the origin of microglia and macrophages in the ischemic lesion, bone marrow from rats expressing green fluorescent protein (GFP) was transplanted into test subjects one month before performing SCI/R. Many GFP(+)/CD68(+) microglia and macrophages were present 7d after SCI/R. Resident (GFP(-)/Iba1(+)/CD68(-)) microglia and bone marrow-derived macrophages (BMDMs; GFP(+)/Iba1(+)/CD68(+)) colocalized in the mild group 7d after SCI/R. In the moderate group, BMDMs outnumbered resident microglia. A greater accumulation of BMDMs expressing insulin-like growth factor-1 (IGF-1) was observed in lesions in the severe group, relative to the moderate group. BMDMs in the severe group strongly expressed tumor necrosis factor α, interleukin-1ß, and inducible nitric oxide synthase, in addition to IGF-1. A robust accumulation of BMDMs occupying the entire ischemic gray matter was observed only in the severe group. These results demonstrate that the magnitude of the microglial and BMDM responses varies considerably, and that it correlates with the severity of the neurological dysfunction. Remarkably, BMDMs appear to have a beneficial effect on the spinal cord in paresis. In contrast, BMDMs seem to exhibit both beneficial and harmful effects in severe paraplegia.

Asymptomatic giant traumatic right coronary artery pseudoaneurysm caused by sternal fracture.

Giant traumatic coronary artery pseudoaneurysm is extremely rare, and very few cases of traumatic coronary artery aneurysm have been previously reported. We present a case of an asymptomatic, giant, traumatic right coronary artery pseudoaneurysm caused by blunt chest trauma and sternal fracture. The risk of rupture or peripheral embolization remains unclear, but we believe that pseudoaneurysm resection and coronary artery bypass grafting are adequate procedures for preventing rupture or ischemia.

Transmural perfusion gradient in adenosine triphosphate stress myocardial perfusion computed tomography.

BACKGROUND: The aim of the present study was to assess semi-quantification of myocardial perfusion using adenosine triphosphate (ATP)-stress myocardial perfusion computed tomography (MPCT) in patients with coronary artery disease (CAD). METHODS AND RESULTS: Seventeen patients with CAD underwent ATP-stress MPCT, stress myocardial perfusion scintigraphy (MPS) and coronary angiography (CAG). With ATP loading (0.16 mg·kg⁻¹·min⁻¹, 5 min) and slow infusion of contrast medium (2 ml/s, 100 ml), stress images were acquired using prospective electrocardiogram-gated 64-slice CT. Stress MPCT images were analyzed according to the transmural perfusion gradient (TMPG; difference between subendocardial and epicardial attenuation, divided by wall thickness; Hounsfield units [HU]/mm) per segment, and summed TMPG was compared with those of stress MPS and CAG per territory and patient, respectively. There were 36 CAG-proved stenotic vessels in 51 (17 × 3) territories. There were significant correlations between TMPG and MPS stress score per segment, per territory and per patient, respectively (P<0.05). Summed TMPG in territories with and without >70% coronary stenosis was 32.3HU/mm (-1.9~90.9) and 14.5 HU/mm (-5.6~38.4; P<0.05). For detecting coronary artery stenosis, sensitivity, specificity, positive and negative predictive values using the summed TMPG were 72%, 87%, 93% and 57%, in comparison with summed MPS (64%, 73%, 85%, and 46%). CONCLUSIONS: Semi-quantification of myocardial perfusion using TMPG has great potential to evaluate the severity of myocardial ischemia, similarly to MPS score.

Pseudoaneurysm in the Left Groin due to Ruptured Knitted Dacron Graft.

An 82-year-old man was admitted to our institution with a painful pulsating mass in the left groin. He had undergone bypass surgery with a bifurcated Cooley double velour knitted Dacron graft to treat aorto-iliac occlusive disease 21 years previously. Computed tomography demonstrated a 35-mm pseudoaneurysm near the distal anastomosis site of the graft. Opening the aneurysm revealed that the graft was disrupted along the guideline. We resected the aneurysm and interposed an expanded polytetrafluoroethylene (ePTFE) graft. Vascular surgeons should consider that grafts can fail in patients with long-term prosthetic grafts.

Primary Pancreatic Lymphoma: The Role of Surgical Treatment.

Primary pancreatic lymphoma (PPL) is a rare disease that is difficult to diagnose preoperatively. We describe the youngest case of PPL treated by surgical excision and chemotherapy. A 16-year-old male presented with abdominal pain and jaundice. Abdominal computed tomography showed a 3.0 × 4.5 cm homogeneously enhanced mass localized between the inferior vena cava and pancreatic head; the common pancreatic duct was dilated and the common bile duct was stenosed. Magnetic resonance imaging findings showed a 4.5 cm tumor localized between the inferior vena cava and pancreatic head with low signal intensity on T1W images and high intensity on T2W images, which enhanced inhomogeneously. Endoscopic retrograde cholangiopancreatography findings were compatible with smooth stenosis of the common bile duct. He was diagnosed as pancreatitis secondary to pancreatic tumor and pylorus-preserving pancreaticoduodenectomy was performed. Postoperative diagnosis was PPL and chemotherapy was performed. After 4 years of treatment he has no signs of recurrence.

Combined ablation of atrial fibrillation and minimally invasive mitral valve surgery: a case report.

A partial lower inverted J sternotomy and an extended transseptal incision provide excellent exposure for minimally invasive mitral valve surgery. However, the extended trasnsseptal incision causes dividing the sinus node artery, which may result in conduction system disturbance and need for permanent pacemaker implantation. Therefore, there is a challenge in the patient who requires concomitant ablation for atrial fibrillation because of possible conduction system disturbance caused by extended transseptal incision. We describe a new strategy for combined ablation of atrial fibrillation with minimally invasive cardiac surgery by a transseptal approach to the mitral valve through a partial lower sternotomy incision. Cryoablation was performed using a T-shaped cryoprobe with a lesion set of pulmonary vein isolation and ablation of the left and right isthmus in performing mitral annuloplasty, tricuspid annuloplasty, and atrial septal defect closure through a limited sternotomy incision. This technique might minimize possible conduction system disturbance and provide good surgical result for the patients who undergo mitral valve surgery and ablation of atrial fibrillation.

Repair of congenitally absent chordae in a tricuspid valve leaflet with hypoplastic papillary muscle using artificial chordae.

Isolated congenital tricuspid regurgitation without downward displacement of the leaflet is uncommon in adults, and repair of such valves often requires a procedure that is more complex than simple tricuspid annuloplasty. We describe a technique of tricuspid valvoplasty using the neo-papillary loop technique to reconstruct multiple artificial chords for isolated congenital tricuspid regurgitation associated with a dysplastic anterior leaflet with agenesis of the chordae tendineae and a hypoplastic anterior papillary muscle. This technique provides a simple and valuable option for the repair of dysplastic valves lacking chordae, even those with a hypoplastic papillary muscle.

Off-pump coronary bypass via left thoracotomy resulting from sternoclavicular arthritis.

We report a case of coronary artery bypass grafting through the left thoracotomy in a patient who suffered from sternoclavicular joint infection with methicillin-resistance Staphylococcus aureus. We performed off-pump coronary bypass surgery, using the left internal thoracic artery to the left anterior descending coronary artery and a saphenous vein graft from the aorta to the circumflex artery, with a successful outcome. This approach seems to be safe and effective for coronary bypass grafting in situations where median sternotomy is not favorable, as in the described patient.

Anomalous subaortic left brachiocephalic vein in surgical cases and literature review.

Anomalous subaortic left brachiocephalic vein (ASLBV) is a rare systemic venous anomaly. We review our experience with patients associated with ASLBV who underwent cardiac surgery at three institutions. From 1989 to 2009, the medical records of surgically treated patients with ASLBV were analyzed; the incidence of ASLBV, clinical characteristics, and associated anatomical findings were assessed. Fifteen patients had ASLBV. All ASLBVs coursed left lateral to the aortic arch, passed under the ascending aorta anterior to the central pulmonary artery, and joined the right brachiocephalic vein. Fourteen patients had congenital heart disease (CHD), and the remaining patient did not have cardiac anomalies. Its incidence was 0.57% (14 of 2,449) in patients with CHD and only 0.02% (1 of 4,805) in patients without CHD. In patients with CHD, 73.3% (11 of 15) of the patients had conotruncal cardiac anomalies such as tetralogy of Fallot, ventricular septal defect with pulmonary atresia, truncus arteriosus, and interruption of the aortic arch. Eight patients had aortic arch anomalies, including right aortic arch and cervical aortic arch. The deletion of chromosomal 22q11.2 was confirmed in two patients, and one patient was diagnosed with DiGeorge syndrome. ASLBV was clinically silent even without any surgical intervention. ASLBV is a very rare anomaly and is highly associated with conotruncal cardiac anomalies and aortic arch anomalies, including right aortic arch and cervical aortic arch. Preoperative diagnosis is important when any surgical interventions are intended, especially, in patients with conotruncal cardiac anomalies.

Regional myocardial blood flow measured by stress multidetector computed tomography as a predictor of recovery of left ventricular function after coronary artery bypass grafting.

BACKGROUND: Multidetector-row computed tomography (MDCT) applications have expanded to evaluation of myocardial blood flow (MBF) and viability. We quantified regional MBF pre- and post-coronary artery bypass grafting (CABG) using adenosine stress and cardiac 64-MDCT, and investigated whether the results predict MBF and left ventricular (LV) function recovery after CABG. METHODS: We studied 321 regions in 19 CABG patients who underwent adenosine stress 64-row MDCT perfusion imaging and cine magnetic resonance imaging pre- and post-CABG. Myocardial blood flow was estimated from linear regression equation slopes using Patlak plot analyses and compared with LV function by measuring wall thickening (%WT) using cine magnetic resonance imaging. RESULTS: Overall mean MBFs were 1.39 +/- 0.49 and 1.95 +/- 0.49 mL/(g min) pre- and post-CABG (P < .0001). Myocardial blood flow in revascularized areas increased significantly (pre-CABG 1.18 +/- 0.45, post-CABG 1.99 +/- 0.66 mL/[g min], P < .001), whereas nonischemic areas showed no difference (1.79 +/- 0.70 and 1.97 +/- 0.46 mL/[g min], P = .14). Revascularized areas with preoperative MBF > or = 0.9 mL/(g min) showed significantly greater MBF improvement than those with preoperative MBF <0.9 mL/(g min) (P = .04). In patients with preoperative LV dysfunction (ejection fraction <40%), %WT in revascularized areas with pre-CABG MBF > or = 0.9 mL/(g min) improved significantly after CABG (pre-%WT 40.9 +/- 22.9, post-%WT 52.8 +/- 20.6, P = .03) versus those with pre-CABG MBF <0.9 mL/(g min) (pre-%WT 53.2 +/- 35.5, post-%WT 42.5 +/- 17.0, P = .40). CONCLUSIONS: Our results demonstrated more significantly increased MBF post-CABG than pre-CABG, particularly in revascularized areas. Regional MBF before CABG may predict MBF and LV function recovery, in the short term, after CABG.

Use of a hand-made balloon-expandable covered stent for native coarctation of the aorta in an adult patient: a report of a first case in Japan.

In western countries, the use of a balloon-expandable covered stent is recommended for the treatment of native coarctation of the aorta (CoA) in adult patients because endovascular bare stents cannot completely prevent complications such as aneurysms or aortic rupture. However, such a product that is appropriate and officially approved is not available in Japan. We developed and used a handmade balloon-expandable covered stent in a 32-year-old patient with native CoA and achieved a good outcome. A Palmaz-Schatz stent (XL 10-series 4010; Johnson & Johnson, Warren, NJ, USA) was covered with an Ube woven-graft (WST series; 18 mm across; Ube Junken Medical, Tokyo, Japan). Because the stent shortens when dilated, one end of the graft was firmly sutured to one end of the stent, whereas the other end of the graft was stitched loosely to the other end of the stent so that it could slide along the struts of the stent to accommodate foreshortening. After meticulous in vitro simulations, the covered stent was implanted with right ventricular overdrive pacing. No complications were observed, and the pressure gradient disappeared. These results indicate that angioplasty using a balloon-expandable covered stent is highly safe and effective for correcting native CoA in adult patients and hopefully in children.

[Nephrotoxicity induced by repeated cycles of oxaliplatin in a Japanese colorectal cancer patient with moderate renal impairment].

There have so far been few reports of the pharmacokinetics of oxaliplatin in patients with renal impairment. This report describes the nephrotoxicity induced by repeated cycles of oxaliplatin in a Japanese colorectal cancer patient with moderate renal impairment(creatinine clearance(Ccr): 20-30mL/min). The patient was a 77-year-old male who had chronic renal impairment and received the modified FOLFOX6 repeated every 2 weeks. In cycle 8, the blood concentration of oxaliplatin(66 mg/m2)was measured as the platinum level to confirm the patient's safety. The serum ultrafiltrate concentrations of platinum were 800, 1, 000, 300, <200, and <200 ng/mLat 1, 2, 3 hr, 1 week, and 2 weeks after the start of infusion, respectively, which were closely comparable with the population pharmacokinetic data in Japanese patients with normal renal function. On the other hand, the serum creatinine value was gradually increased after cycle 6, resulting in a decrease of Ccr. The mean Ccr during day 1-59 and day 240-299were significantly different at 26. 5+/-2. 8(mean+/-SD)and 9. 6+/-1. 9mL/min, respectively. Consequently, the chemotherapy showed a complete response after 10 cycles, but the patient got dialysis on day 311. In conclusion, the repeated cycles of oxaliplatin cumulatively damaged the renal function in a Japanese patient with a moderate renal impairment.

Cervical aortic arch and Kommerell's diverticulum associated with the anomalous subaortic left brachiocephalic vein in a patient with chromosome 22q11.2 deletion.

We report the surgical case of an eight-year-old girl who had a very rare combination of ventricular septal defect and abnormal aortic arch anatomy: right cervical aortic arch, left descending aorta and Kommerell's diverticulum from which the left subclavian artery arose with anomalous subaortic left brachiocephalic vein. She was confirmed the chromosomal 22q11.2 deletion.