[Thoracic Endovascular Aortic Repair( TEVAR) Deployed into the False Lumen:Report of a Case].

A 73-year-old man had Stanford type B acute aortic dissection 11 years before. He had underwent thoracoabdominal aortic replacement due to thoracoabdominal aneurysm nine years before and hemiarch aortic replacement due to Stanford type A acute aortic dissection four years before. We performed surgery because the dissecting aortic aneurysm in the distal arch has enlarged. We selected thoracic endovascular aortic repair( TEVAR) because of reoperation, but the true lumen of the descending aorta was highly narrowed, we had to deploy stent-grafts into the false lumen. Since the proximal and distal parts of endovascular thoracic stent-grafts were deployed into the previously implanted Dacron grafts, we could deploy them without vascular injury. If both proximal and distal parts of stent-grafts can be deployed into vascular prosthesis, deploying the stent-grafts into the false lumen may be a feasible option.

[Left Atrial Myxoma with Coronary Artery-left Atrial Fistula:Report of a Case].

A 76-year-old woman underwent screening echocardiography. A cardiac mass was detected in the left atrium. It was located at the atrial septum, and was around 3 cm in size. Its surface was smooth and there was cystic cavity inside. Coronary angiography revealed rich blood flow from bilateral coronary arteries to the mass and massive shunt to the left atrium, which formed a fistulous connection. We performed tumor resection under cardiopulmonary bypass. Postoperative course was uneventful. Histopathologically, the tumor was myxoma. Cardiac myxoma is the most common primary cardiac tumor, but myxoma exhibiting coronary artery-left atrial fistula is fairly uncommon.

[Cardiac Tamponade due to a Ruptured Giant Coronary Artery Aneurysm].

We report a case of a ruptured coronary artery aneurysm. An 87-year-old woman suffered from cardiac tamponade due to a ruptured coronary artery aneurysm. Coronary angiography showed a giant coronary aneurysm without coronary artery fistula. Emergency surgery was performed through median sternotomy. We performed aneurysmectomy and ligation of the perfusion arteries under cardiopulmonary bypass. The patient's postoperative course was uneventful. We also reviewed nine cases of ruptured coronary artery aneurysm without coronary artery fistula in Japan. The disease is a rare clinical state and considered to be an indication for emergency surgery.

Efficacy of Direct Oral Anticoagulant into the Care of Venous Thromboembolism Related to Kumamoto Earthquake.

Kumamoto was hit by a series of strong earthquakes beginning on April 14, 2016. We treated many deep vein thrombosis (DVT) patients and pulmonary thrombosis (PTE) patients. We came up with a strategy for diagnosis and therapy of venous thromboembolism (VTE). For VTE patients, we prescribed anticoagulant drugs, mainly direct oral anticoagulant (DOAC). To evaluate the validity and safety of the medical strategy for VTE in disasters, we investigated the prognosis of VTE patients at 4 months after the initial quake. In the two months following the initial quake we attended to 43 VTE patients, 11 PTE patients (including 9 patients with both DVT and PTE) and 32 DVT patients. We prescribed DOAC to 34 patients and Warfarin to 4 patients. Based on the survey at 4 months after the first tremblor, the period of anticoagulation therapy was 95.0±17.2 days for PTE and 57.1±36.5 days for DVT and 12 patients were continuing to take anticoagulant drugs. There were no recurrent VTE or bleeding events. DOAC therapy of VTE is therefore considered effective and safe in the event of a natural disaster. (This is a translation of J Jpn Coll Angiol 2017; 57: 33-40.).

[Surgical Treatment for Anomalous Aortic Origin of Coronary Arteries].

Anomalous aortic origin of coronary arteries is rare. We report 3 cases of surgical treatment for anomalous aortic origin of coronary arteries. Case 1 was a 38-year-old man who was saved by the use of an automated external defibrillator from cardiopulmonary arrest while exercising. The coronary angiogram showed the right coronary artery arising from the left coronary sinus of Valsalva and being located between the aorta and the pulmonary trunk. He underwent coronary artery bypass grafting (CABG) using the right internal thoracic artery with ligation of proximal part of right coronary artery to prevent sudden death. Case 2 was a 76-year-old woman with the left coronary artery arising from the right coronary sinus of Valsalva and proximal left anterior descending coronary artery stenosis. She underwent CABG. Case 3 was a 58-year-old man with severe aortic valve regurgitation. He underwent aortic valve replacement. During weaning from cardiopulmonary bypass, the electrocardiogram revealed ST-segment elevation. Transesophageal echocardiography showed intramural segment of the left coronary artery and obstruction of the left coronary blood flow. Repair was accomplished by unroofing the intramural segment. All the cases were successfully treated by surgical treatment.

[Giant Left Atrium with Mitral Regurgitation in Williams Syndrome: Report of a Case].

A 43-year-old woman with a history of mitral regurgitation and Williams syndrome was admitted for the treatment of congestive heart failure. A computed tomography scan showed a giant left atrium. No other cardiac abnormalities were observed. She received mitral valve replacement with a mechanical valve prosthesis and underwent left atrium volume reduction with a suture technique and modified Maze procedure. After the operation, the cardiac rhythm returned to sinus rhythm and chest radiography showed normal cardiothoracic ratio. Congestive heart failure did not recur.

Sinus node artery-preserving superior transseptal approach: a simple technique.

With the use of the superior transseptal approach during mitral valve surgery, good exposure of the mitral valve can be achieved with simple traction sutures, which minimize the risk of deformation of the mitral valve. For this reason, we routinely perform mitral valvoplasty using the superior transseptal approach; however, we, occasionally encounter cases that develop postoperative atrial dysrhythmia. We have therefore, devised a very simple technique for preservation of the sinus node artery in the superior transseptal approach, which is effective for reducing the incidence of postoperative sinus node dysfunction. In this technique, during incision of the dome of the left atrium, the sinus node artery is carefully dissected and preserved.

The value of angiogenic therapy with intramyocardial administration of basic fibroblast growth factor to treat severe coronary artery disease.

BACKGROUND: Basic fibroblast growth factor (bFGF) was administered intramyocardially together with CABG to induce myocardial neovascularizaton and collateral growth in patients with ungraftable coronary arteries. Coronary angiographic and myocardial scintigraphic findings revealed that the effects of CABG were potentially confounding. METHODS AND RESULTS: Patients in the bFGF group (n = 16) underwent angiogenic therapy using bFGF for ungraftable territory, and incomplete revascularization (IR) patients (n = 22) underwent only CABG. The magnitude of collateral development was assessed by the Rentrop score and collateral connection (CC) grade. Rentrop scores tended to increase among patients in the bFGF group (before vs. after surgery, 1.9 ± 1.2 vs. 2.3 ± 1.2, p = 0.05), but not in the IR group. The CC grade significantly increased among patients in the bFGF group (before vs. after surgery, 1.0 ± 0.9 vs. 1.4 ± 0.5, p <0.05), but not in the IR group. Myocardial perfusion in territories injected with bFGF improved in 13 patients (81%) of the bFGF group, and also in the nonbypassed territory in 4 IR patients (25%) (p <0.05). CONCLUSION: Angiogenic therapy with bFGF induced collateral development and improved myocardial perfusion in territories injected with bFGF.

Different roles of Foxo1 and Foxo3 in the control of endothelial cell morphology.

Foxo1, a member of the Foxo subfamily of forkhead box transcription factors, is known to be essential for progression of normal vascular development in the mouse embryos. In the cultures of endothelial cells derived from embryonic stem cells, Foxo1-deficient endothelial cells exhibit an abnormal morphological response to vascular endothelial growth factor-A (VEGF-A), which is characterized by a lack of cell elongation, yet the molecular mechanisms governing endothelial cell morphology under angiogenic stimulation remain unknown. Here, we report that transforming growth actor-beta also induces endothelial cell elongation in collaboration with Foxo1 and VEGF-A. Furthermore, tetracycline-regulated induction of Foxo3, another member of the Foxo subfamily, into Foxo1-null endothelial cells failed to restore abnormal morphological response to VEGF-A at an early differentiation stage. In contrast, Foxo1 and Foxo3 exerted the same function at a late differentiation stage, i.e. enhancement of VEGF responsiveness and promotion of cell elongation. Our results provide evidence that endothelial cell morphology is regulated by several mechanisms in which Foxo1 and Foxo3 express distinct functional properties depending on differentiation stages.

Therapeutic angiogenesis with autologous hepatic tissue implantation and omental wrapping.

BACKGROUND: The liver produces various angiogenic and cytoprotective growth factors and the omentum has potent angiogenic properties that promote wound healing. The ability of hepatic tissue implantation plus omental wrapping to induce angiogenesis and restore cardiac function was investigated in a rat model of infarction. METHODS AND RESULTS: Myocardial infarction was induced in rats using coronary artery ligation. The omentum was wrapped (omentopexy group), hepatic tissue implantation was combined with omental wrapping (hepatic tissue implantation (H) group) or no other treatment was applied (control (C) group), and then ventricular function was evaluated by echocardiography 4 weeks later. Infarct size, ventricular remodeling, vascular density and collagen density were morphometrically and histologically evaluated. The expression of angiogenic growth factors in implanted tissues was examined using RT-PCR. The H group had thicker (p<0.05) and less expanded infarcts (p<0.001), as well as higher capillary (p<0.01) and arteriolar (p<0.05) density in the infarct border zone, than the C group. Hepatocyte growth factor was obviously expressed and the expression of both basic fibroblast growth factor and vascular endothelial growth factor was increased in the H group. CONCLUSIONS: Hepatic tissue implantation combined with omental wrapping stimulated angiogenesis, attenuated left ventricular remodeling and improved cardiac function.