Evaluation of VEGF-A in platelet and microRNA-126 in serum after coronary artery bypass grafting.

Platelet functions are thought to contribute to clinical outcomes after heart surgery. This study was conducted to assess the pivotal roles of vascular endothelial growth factor-A (VEGF-A) and microRNA-126 (miR-126) during coronary artery bypass grafting (CABG). Whole blood was collected for platelet isolation from 67 patients who underwent CABG surgery between July 2013 and March 2014. VEGF-A and miR-126 levels in serum, plasma, and platelets were measured at various time points and compared with clinical characteristics. The platelet count was decreased at 3 days after CABG. This dynamic change in platelet count was larger after conventional coronary artery bypass (CCAB) than off-pump coronary artery bypass (OPCAB). VEGF-A in the same number of platelets (IP-VEGF-A) was increased at 3 days after CABG, followed by an increase of VEGF-A in serum (S-VEGF-A) at 7 days after surgery. The miR-126-3p level in serum (S-miR-126-3p) increased rapidly after CABG and then decreased below preoperative levels. The IP-VEGF-A level on day 7 after CABG in patients with peripheral artery disease (PAD), who suffered from endothelial dysfunction, was higher compared with patients without PAD. Conversely, S-miR-126-3p on day 7 after surgery was lower in patients with PAD than in patients without PAD. Low levels of S-miR-126-3p due to endothelial dysfunction may lead to high IP-VEGF-A, which is closely related to complications after CABG.

Combination treatment using percutaneous transluminal angioplasty and low-density lipoprotein apheresis in a patient with peripheral arterial disease and a history of chronic hemodialysis.

Peripheral arterial disease (PAD) is very common in dialysis patients, who tend to have diffuse calcification and severe peripheral arterial stenosis that make it difficult to treat limbs using only surgical or endovascular interventions. Better ways to treat this condition are therefore required and also follow-up studies to evaluate the effects of these treatments on the microcirculation. A 59-year-old man who had a cadaveric kidney transplant five years previously after 25 years of regular hemodialysis complained of pain at rest in his right lower limb and subsequently developed an intractable decubitus ulcer on his right fifth toe (Fontaine IV). Digital subtraction angiography revealed a severe obstruction of the right femoral artery and diffuse stenosis of the right superficial femoral artery. The patient underwent percutaneous transluminal angioplasty (PTA) and six sessions of low-density lipoprotein apheresis (LDL apheresis). At the end of these sessions his complaints were almost completely alleviated. The mean elevation in skin temperature after each session was (1.58 ± 0.99)°C [mean ± SD] over the right dorsalis pedis artery and (1.52 ± 0.88)°C at the tip of the right fifth toe. Ultrasound-measured blood flow rates in the right dorsalis pedis artery were 9.2 cm/s before PTA and 20.2 cm/s one month after PTA. Hemodialysis was resumed 3 days after the PTA due to contrast-induced nephropathy. The combination of PTA and LDL apheresis is useful for treating PAD in hemodialysis patients, with the changes in peripheral artery patency are able to be evaluated effectively by measuring skin temperature.

Perforation of the Brachial Artery During Percutaneous Lower Extremity Angioplasty via the Brachial Artery Approach Resulting in Difficulties in Balloon Catheter Removal: A Case Report.

Percutaneous endovascular treatment of peripheral vascular disease with small-caliber short sheaths may lead to device removal difficulties. A 50-year-old woman on hemodialysis underwent endovascular intervention for right common femoral artery stenosis, via the right brachial artery. A 4-Fr short sheath was used for the procedure owing to a previous hematoma at the puncture site. However, the balloon catheter could not cross the calcified lesion and was difficult to remove. A microcatheter was inserted and withdrawn, but the guidewire was kinked and could not be retrieved. Surgical retrieval of the guidewire and balloon catheter was performed. The kinked guidewire and microcatheter had migrated outside the vessel. In peripheral vascular intervention, the use of a long sheath in the brachial artery approach is important. Forcible removal of a difficult-to-remove catheter may cause further vascular damage. Therefore, it is essential to stop immediately and consider surgical treatment.

Use of continuous retrograde gaseous oxygen persufflation for myocardial protection during open heart surgery.

PURPOSE: The infusion of a cardioplegic solution is the standard method of myocardial protection during open heart surgery. However, this method interrupts the surgical procedure and it is difficult to ensure a bloodless surgical field. To address these problems, the effect of continuous retrograde gaseous oxygen persufflation (ROP) on myocardial protection was assessed in comparison to St. Thomas' solution (STS). METHODS: Eighteen adult mongrel dogs were divided into three groups of six. Group G received continuous ROP, Group C received STS every 30 min, and Group N received hypothermia alone during the 120 min hypothermic ischemia. The myocardial metabolism was assessed by measuring the coronary sinus lactate concentration, lactate extraction ratio (LER), coronary sinus lipid peroxidation (LPO) concentration, left ventricular myocardial adenosine triphosphate (ATP) concentration, and water content. Cardiac function was assessed by the percent recovery relative to the baseline. RESULTS: In Group G, the lactate, LPO, and water content were significantly lower (P = 0.0062, P = 0.03, and P = 0.0065, respectively), and ATP was significantly higher (P = 0.028) than in Group C. The LER was only positive in Group G. In addition, the cardiac functions in Groups G and C were not significantly different. CONCLUSIONS: Retrograde gaseous oxygen persufflation was not inferior to STS in regard to myocardial protection. This technique could therefore represent a potentially promising cardioplegic method.

Aortic fenestration for type B chronic aortic dissection complicated with lower limb malperfusion induced by walking exercise.

We report a case of a 55-year-old male with type B-chronic aortic dissection. Patient presented with intermittent claudication due to limb malperfusion resulting from expansion of a patent false lumen during walking regardless of normal range ankle-brachial index (ABI) at rest. Preoperative stress vascular ultrasonography was an effective modality for proper diagnosis. We should be concerned of reversible ischemia due to the dissection flap in patients with type B aortic dissection. Fenestration of the aorta can be a choice of treatment in such patients. The patient has been doing well with no ischemia for 3.5 years after the operation.

Emergent rescue operation for expanding mycotic pseudoaneurysm causing hemoptysis, originating from right subclavian artery.

Mycotic pseudoaneurysm of the subclavian artery is uncommon and its therapeutic strategy has not been established. We report a case of 81-year-old woman with mycotic pseudoaneurysm in the right subclavian artery. Blood culture showed Enterobacter cloacae. Because of hemoptysis and acute expansion of the pseudoaneurysm, emergent coil embolization was performed, but failed. The patient underwent urgent operation for an en-bloc resection of the pseudoaneurysm after aorto-right common carotid artery bypass followed by omentum packing. The patient underwent continuous wound irrigation for 3 weeks. The postoperative course was uneventful and without recurrence of infection.

Long-term follow up in patients receiving a small aortic valve prosthesis.

BACKGROUND AND AIMS OF THE STUDY: Concern persists regarding the long-term effects of aortic valve replacement (AVR) in the small aortic root. METHODS: Twenty-eight patients (21 females, seven males; mean age 54.1+/-11.7 years; mean body surface area (BSA) 1.39+/-0.07 m2) who underwent AVR with a 19 mm mechanical valve more than 10 years previously at the authors' institute, were followed up. Long-term echocardiographic evaluations were performed in 18 of 21 survivors. RESULTS: Follow up in the 28 patients was complete for up to 19.2 years (mean 11.4 years); cumulative follow up was 318.1 patient-years. Actuarial survival rates at 5, 10 and 15 years were 88.5+/-6.3%, 72.0+/-9.0% and 72.0+/-9.0%, respectively. In general, NYHA class showed satisfactory improvement. Long-term echocardiography showed significant reductions in left ventricular (LV) wall thickness and mass index compared with preoperative values, despite the existence of pressure gradients. A negative correlation was found between the rate of reduction of LV wall thickness and BSA. CONCLUSION: Implantation of the 19 mm aortic mechanical prosthesis was viable in patients with a small aortic annulus, especially if their BSA was <1.45 m2.

Posterior mitral annuloplasty with a flexible linear reducer.

OBJECTIVES: We evaluated posterior annuloplasty results using a flexible linear reducer, especially as a cardiac surgical procedure. METHODS: Subjects were 24 patients consisting of 20 men and 4 women aged 7 to 79 years (mean; 61.3 years) with mitral regurgitation who underwent mitral valve reconstruction using a flexible linear reducer from May 1999 to April 2001. Mitral regurgitation was attributed to myocardial ischemia in 9 (37.5%). Isolated mitral valve repair was conducted only in 3 (12.5%) and concomitant procedures in 21 (87.5%). RESULTS: No operative deaths occurred. One hospital death (4.2%) occurred due to cardiac failure on postoperative day 58. Four late deaths (16.7%) occurred 8 to 15 months after surgery due to heart failure, stroke, and cancer. No patients required reoperation and no perioperative complications occurred. Doppler echocardiography conducted in all patients within a month postoperatively showed excellent valve function: 11 (45.8%) had no residual regurgitation, 5 (20.8%) had trivial insufficiency, 6 (25%) had mild insufficiency, 2 (8.3%) had moderate insufficiency, and none had severe insufficiency. We observed significantly reducted enddiastolic and systolic left ventricular diameter while ejection fraction remained unchanged. CONCLUSIONS: Posterior mitral annuloplasty using a flexible linear reducer is simple, saves time, and is useful for the small left atrium and as an additional procedure in other cardiac surgery.

Herpes simplex viral pneumonia after coronary artery bypass grafting.

We report a case of herpes simplex viral (HSV) pneumonia as a post-CABG pulmonary complication in a 70-year-old man. Chest radiography on postoperative day 9, showed a glass-like shadow and pleural effusion in the left lung field, and the man's condition began deteriorating rapidly. Bronchofiberscopy to detect the pathogen and a bronchoalveolar lavage with polymerase chain reaction (PCR) yielded a definitive diagnosis of HSV pneumonia. Once therapy with acyclovir was begun, his condition improved markedly. Our case suggests that 1 viral pulmonary infection should be considered as a possible cause in postoperative cardiac patients with unexplained progressive pulmonary infiltrates, and 2 DNA amplification using PCR is rapid--it can be completed within 1 day--and sensitive and specific in diagnosing such infections.