[Congenital Left Internal Mammary Artery to Pulmonary Artery Fistula with Aneurysmal Change Diagnosed Incidentally:Report of a Case].

An internal mammary artery to pulmonary artery (IMA-PA) fistula is a very rare vascular abnormality. Patients with this disease are often asymptomatic, but they may develop symptoms such as heart failure and hemoptysis. A 60-year-old woman was incidentally diagnosed with left IMA-PA fistula by chest computed tomography (CT) during an examination for colon cancer. She was asymptomatic, but we determined that surgery was indicated because of the presence of an aneurysmal change. We performed complete surgical resection of the IMA-PA fistula and aneurysm under cardiopulmonary bypass. Her postoperative course was uneventful. Although a specific management strategy for IMA-PA fistula has not yet been established, surgical treatment should be performed to prevent rupture in cases with aneurysmal change.

[Successful Pulmonary Embolectomy using a Bronchoscope:Report of a Case].

Surgical pulmonary embolectomy is indicated for acute massive pulmonary thromboembolism complicated by floating thrombi in the right heart system. Postoperative residual thrombi are associated with persistent pulmonary hypertension and subsequent right heart failure, resulting in poor surgical outcome. A 67-year-old man was admitted to our institution owing to dyspnea on exertion. Transthoracic echocardiography revealed a floating right atrial mass and right ventricular overload. In addition, enhanced computed tomography (CT) showed a right atrial mass as well as bilateral massive pulmonary embolism. We performed an urgent pulmonary embolectomy using a bronchoscope as an adjunctive angioscope to completely remove the peripheral thrombi and to prevent serious complications, such as endobronchial hemorrhage due to pulmonary arterial injury. A clear, bloodless view of peripheral pulmonary arteries was obtained using short intermittent circulatory arrest technique. Postoperative course was uneventful, and he was discharged ambulatory 20 days after the surgery without any symptoms.

[Pacemaker Dislocation into the Peritoneal Cavity].

A 16-day-old neonate with congenital complete atrioventricular block underwent epicardial pacemaker implantation under the rectus. Four months later, abodominal X-ray imaging revealed dislocation of the generator from the abdomen to the pelvis. The infant was diagnosed with intraperitoneal pacemaker dislocation. However, there were no abdominal manifestations or complications associated with the bowel, urinary tract, and vascular system. Surgical refixation was performed in a hybrid room. Fluoroscopy helped avoid bowel injury when removing the generator from the peritoneal cavity. The pacing lead, which was adherent and entangled with the omentum, was released under direct vision. The generator was placed in a new pocket created in the subcutaneous layer of the anterior fascia of the rectus.

Superior Mesenteric Artery-Pancreaticoduodenal Arcade Bypass Grafting for Repair of Inferior Pancreaticoduodenal Artery Aneurysm with Celiac Axis Occlusion.

We report a case of an aneurysm of the inferior pancreaticoduodenal artery (IPDA), with chronic occlusion of the celiac axis. Both surgical aneurysmectomy and endovascular coil embolization were anticipated to sacrifice IPDA, which could lead to severe acute ischemia in the celiac region. The treatment involved surgical ligation of the aneurysm after bypass grafting from the superior mesenteric artery to the anterior IPDA. A postoperative computed tomography revealed no enhancement of the aneurysm and sufficient collateral blood supply by the patent bypass graft.

Effect of exogenous Oct4 overexpression on cardiomyocyte differentiation of human amniotic mesenchymal cells.

Regenerative therapy is a new strategy for the end-stage heart failure; however, the ideal cell source has not yet been established for this therapy. We expected that the amnion might be an ideal cell source for cardiac regenerative therapy and that the differentiation potency of the human amnion mesenchymal cells (hAMCs) could be improved by overexpression of Oct4, a key factor that maintains the undifferentiated state. A plasmid vector was made by insertion of the Oct4 open reading frame (ORF) under control of a cytomegalovirus (CMV) promoter (pCMV-hOct4) and transfected into hAMCs by electroporation. The optimum induction time was investigated by comparing the quantity of stem cell-specific mRNAs, cardiac-specific mRNAs, and cardiac-specific proteins with time. hAMCs already expressed cardiac-specific proteins such as Nkx2.5 and Connexin43. After pCMV-hOct4 transfection, endogenous Oct4 mRNA and other stem cell markers showed a transient increase. With 5-azacytidine treatment, quantities of the cardiac-specific mRNAs, such as GATA4 and myosin light-chain-2v (Mlc-2v), were increased significantly. After Oct4 overexpression, the highest expression of cardiac-specific mRNAs and stem cell makers was seen at almost the same time. Furthermore, more mature myocardial contraction proteins were observed when hAMCs were induced at specific optimal times after gene transfection. In conclusion, hAMCs were activated to an undifferentiated state by overexpression of Oct4, and their cardiac differentiation potency was improved. Thus, the single-time transfection of the Oct4 expression vector may be a useful strategy for effective cell therapy. The use of cryopreserved hAMCs in cell therapy still requires more investigation.

Selective isolation of nanog-positive human amniotic mesenchymal cells and differentiation into cardiomyocytes.

Adult cardiomyocytes have little ability to regenerate, thus cardiac regeneration therapy represents a potential method for treating severe heart failure. Human amniotic mesenchymal cells (hAMCs) have the potential to be a useful cell source for cardiac regeneration therapy. We attempted to isolate stem cells from hAMCs and differentiate them into cardiomyocytes. Nanog promoter-Cre plasmid and cytomegalovirus (CMV) promoter-loxP-STOP-loxP-Red-puro(r) plasmid were co-transfected into immortalized hAMCs (iHAMs). Nanog-positive iHAMs were treated with 5-azacytidine (5-aza), trichostatin A (TA), activin A (AA), and bone morphogenetic protein-4 (BMP-4), or co-cultured with murine fetal cardiomyocytes for cardiomyocytes differentiation. Isolated Nanog-positive iHAMs were analyzed by quantitative RT-PCR and immunofluorescent staining before and after differentiation. Expression of Nanog, Oct3/4, Sox2, and Klf4 was significantly higher in Nanog-positive than in Nanog-negative iHAMs. Nanog-positive iHAMs were stained for Nanog and Oct3/4 in the nucleus. Nanog-positive iHAMs treated with 5-aza expressed Nkx2.5, GATA-4, human atrial natriuretic peptide (hANP), cardiac troponin T (cTnT), myocin light chain (Mlc)-2a, Mlc-2v, ß-myosin heavy chain (ß-MHC), hyperpolarization-activated cyclic nucleotide gated channels (HCN)-4, and inwardly rectifying potassium channels (Kir)-2.1. Although Nanog-positive iHAMs treated with TA, AA, or BMP-4 expressed several cardiac markers, no contraction was observed. Co-cultured Nanog-positive iHAMs with murine fetal cardiomyocytes spontaneously contracted in a synchronized manner and expressed the cardiac markers. In conclusion, Nanog-positive hAMCs with characteristics of stem cells were isolated and differentiated into cardiomyocyte-like cells, suggesting that these isolated hAMCs could be a useful cell source for cardiac regeneration therapy.

Surgical management of multiple ventricular septal defects: the role of the felt sandwich technique.

OBJECTIVE: Recently, the felt sandwich technique has been widely used to close muscular ventricular septal defects. We evaluated the early and midterm results of our strategy (a combination of the sandwich technique and direct closures) and assessed the role of the sandwich technique in the treatment of multiple ventricular septal defects. METHODS: Twenty-nine consecutive patients underwent an operation for multiple ventricular septal defects and associated cardiac malformations. They included 17 boys and 12 girls with a median age of 6.0 months. Thirteen patients had 4 or more ventricular septal defects (Swiss cheese septum). RESULTS: There was no surgical or follow-up mortality, and no reoperations were required. There were no cases of heart block and no significant residual shunts in the latest follow-up study. Two patients with Swiss cheese septum had postoperative congestive heart failure. Three muscular ventricular septal defects were closed with the sandwich technique in these 2 patients, whereas 1 or fewer ventricular septal defects were closed with the sandwich technique in the other 27 patients. Seven (77.8%) of 9 patients who underwent the sandwich procedure had septal dysfunction, whereas 5 (25.0%) of the other 20 patients showed septal dysfunction (P < .05). CONCLUSIONS: The outcome of the surgical repair of multiple ventricular septal defects was satisfactory. Although the sandwich technique is simple and effective, the use of numerous felt patches disturbed the movement of the interventricular septum. An effort should be made to close the muscular ventricular septal defect directly to avoid postoperative cardiac dysfunction. Large apical ventricular septal defects, especially those located just underneath the moderator band, are considered suitable for the sandwich technique.

An infected pseudoaneurysm following a modified Blalock-Taussig shunt.

A two-month-old male infant with tetralogy of Fallot underwent a right-sided modified Blalock-Taussig shunt using a 4 mm expanded polytetrafluoroethylene graft through a right thoracotomy. Five months later, the patient developed otitis media, followed by repeated relapses of pneumonia and fever of unknown origin. Multidetector-row computed tomography and angiography, performed at 12 months of age, revealed a pseudoaneurysm of the subclavian artery at the insertion of the modified Blalock-Taussig shunt. After 20 days of antibiotic therapy, the pseudoaneurysm and infected graft were successfully resected through a median sternotomy approach. This report describes the treatment strategy of this rare but potentially fatal complication after a modified Blalock-Taussig shunt operation.

Open heart operation in a child with congenital heart disease and hereditary spherocytosis.

An 18-month-old girl with hereditary spherocytosis underwent closure of the ventricular septal defect, commissurotomy of the pulmonary valve, and patch angioplasty of the pulmonary trunk without previous splenectomy. No serious complications as a result of hemolysis occurred in the perioperative period. Open heart surgery can therefore be safely performed in young children with congenital heart disease and hereditary spherocytosis who have not previously undergone splenectomy.