Surgical Management of Cardiac Implantable Electronic Device Complications in Patients Unsuitable for Transvenous Lead Extraction.

BACKGROUND: Although surgical approaches for infected or failing cardiac implantable electronic device (CIED) leads are more invasive than transvenous approaches, they are still required for patients considered unsuitable for transvenous procedures. In this study, surgical management with transvenous equipment for CIED complications was examined in patients unsuitable for transvenous lead extraction.Methods and Results: We retrospectively examined 152 consecutive patients who underwent CIED extraction between April 2009 and December 2021 at the Department of Cardiovascular Surgery, Nippon Medical School. Nine patients (5.9%; mean [±SD] age 61.7±16.7 years) who underwent open heart surgery were identified as unsuitable for the isolated transvenous approach. CIED types included 5 pacemakers and 4 implantable cardioverter-defibrillators; the mean [±SD] lead age was 19.5±7.0 years. Indications for surgical management according to Heart Rhythm Society guidelines included failed prior to transvenous CIED extraction (n=6), intracardiac vegetation (n=2), and severe lead adhesion (n=1). Transvenous CIED extraction tools were used in all patients during or before surgery. Additional surgical procedures with CIED extraction included epicardial lead implantation (n=4) and tricuspid valve repair (n=3). All patients were discharged; during the follow-up period (mean 5.7±3.7 years), only 1 patient died (non-cardiac cause). CONCLUSIONS: Surgical procedures and transvenous extraction tools were combined in the removal strategy for efficacious surgical management of CIED leads. Intensive surgical procedures were safely performed in patients unsuitable for transvenous extraction.

Analysis of the Pancreatic Cancer Microbiome Using Endoscopic Ultrasound-Guided Fine-Needle Aspiration-Derived Samples.

OBJECTIVES: Most previous studies have analyzed bacteria in tumors using resected pancreatic cancer (PC) tissues, because it is difficult to obtain tissue samples from unresectable advanced PC. We aimed to determine whether minimal tissue obtained by endoscopic ultrasound-guided fine-needle aspiration is useful for microbiome analysis. METHODS: Thirty PC and matched duodenal and stomach tissues (N = 90) were prospectively collected from 30 patients who underwent endoscopic ultrasound-guided fine-needle aspiration. Bacterial DNA was extracted, and 16S rRNA sequencing was performed. The primary outcome was the success rate of bacterial detection in tumors. Bacterial diversity and structure were investigated. RESULTS: The bacterial detection rates were 80%, 100%, and 97% in PC, gastric, and duodenal samples, respectively. Pancreatic cancer tissues showed a lower α-diversity and a significantly different microbial structure than stomach and duodenal tissues. Proteobacteria were more abundant, whereas Firmicutes, Bacteroidetes, and Fusobacteria were less abundant in PC tissues than in stomach and duodenal tissues. Acinetobacter was more abundant in PC tissues than in stomach and duodenal tissues, and Delftia was more frequently detected in resectable PC. CONCLUSIONS: Endoscopic ultrasound-guided fine-needle aspiration samples were valuable for PC microbiome analysis, revealing that the bacterial composition of PC is different from that of the stomach and duodenum.

Sulfobetaine polymers for effective permeability into multicellular tumor spheroids (MCTSs).

Multicellular tumor spheroids (MCTSs) are attractive for drug screening before animal tests because they emulate an in vivo microenvironment. The permeability of the MCTSs and tumor tissues towards the candidate drugs is not sufficient even though the drugs can penetrate monolayer cultured cells; therefore, nanocarriers are required to enhance permeability and deliver drugs. In this study, we prepared zwitterionic polymers of sulfobetaine methacrylates and (meth)acrylamides with or without hydroxy groups between the zwitterions to serve as highly permeable nanocarriers. In the sulfobetaine polymers, poly(2-hydroxy-3-((3-methacrylamidopropyl)dimethylammonio)propane-1-sulfonate), P(OH-MAAmSB), the hydroxy group containing methacrylamide polymer exhibited little cytotoxicity and membrane translocation ability against monolayer cultured cells. Moreover, the excellent permeability of the hepatocyte MCTS enabled P(OH-MAAmSB) to permeate it and reach the center region (∼325 µm in diameter) at approximately 150 s, although poly(trimethyl-2-methacroyloxyethylammonium), a cationic polymer, penetrated just 1 to 2 layers from the periphery. The superior permeability of P(OH-MAAmSB) might be due to its good solubility and side chain conformation. P(OH-MAAmSB) is a promising nanocarrier with membrane translocation and permeability.

Protocol for cortical-wide field-of-view two-photon imaging with quick neonatal adeno-associated virus injection.

We recently established a simple and versatile adeno-associated virus (AAV) induction approach that enables dense (>90% labeled neurons) and cortical-wide Ca2+ sensor expression. Here, we describe the stepwise protocol for neonatal AAV injection of a Ca2+ sensor. We also detail the steps for subsequent craniotomy to generate a chronic cranial window, followed by wide-field two-photon Ca2+ imaging in an awake mouse. This protocol serves as an alternative to the use of transgenic animals and offers translatable options for cortical-wide experiments. For complete details on the use and execution of this protocol, please refer to Ota et al. (2021).

[A Case of Gastric Perforation Due to an Unresectable Advanced Gastric Cancer That Achieved pCR after Conversion Surgery following SOX plus T-mab Therapy].

This case pertains to a 72-year-old man who visited the emergency department with a complaint of upper abdominal pain. On examination, we suspected gastric perforation due to gastric cancer and decided to perform emergency surgery. We performed laparoscopic omentoplasty and collected #4d lymph nodes that were enlarged on CT. The pathological diagnosis was lymph node metastasis. Based on CT findings, we determined it was Bulky N. For initial management, we performed 3 preoperative chemotherapy(SOX therapy)courses and staging laparoscopy. On surgery, extensive disseminated nodules on the abdominal wall, stomach wall, and liver surface were found, and ascites cytology revealed positive findings. Therefore, we did not perform primary lesion resection. Although the disseminated nodule did not pathologically show tumor cells, CY1 was found, resulting to a diagnosis of unresectable gastric cancer. Since the tumor was HER2 3+, we initiated SOX/trastuzumab therapy. After 16 courses, staging laparoscopy was performed as the lymph nodes had shrunk significantly. The results showed no tumor cells in ascites and the disseminated nodules, and laparoscopic total gastrectomy was subsequently performed. Pathological findings showed no tumor cells in the primary lesion or lymph nodes; therefore, a diagnosis of pathological complete response was made. Currently, the patient is alive without recurrence for 6 months after surgery.

Intra-Extracardiac Total Cavopulmonary Connection for Patients With Anatomical Complexity.

BACKGROUND: Currently, the extracardiac conduit total cavopulmonary connection (eTCPC) is the most widely used for Fontan modification worldwide. Nevertheless, there have been some cases that are difficult for performing eTCPC because of their anatomical complexity, such as apicocaval juxtaposition. For such cases, in 2002, we introduced the intra-extracardiac TCPC (ieTCPC). METHODS: We reviewed our 20-year single-center experience with 316 TCPC patients to compare eTCPC (n = 277) and ieTCPC (n = 39) in terms of mortality and morbidity. ieTCPC was indicated for the cases in which there was concern that the TCPC conduit would be too curved for ordinary eTCPC. RESULTS: Early death occurred in 1 patient and late death occurred in 15 patients. The actuarial survival rate in the eTCPC and the ieTCPC groups at 10 years were 95.1% and 100.0%, respectively. There was no significant difference in actuarial survival between eTCPC and ieTCPC patients. In the multivariate analysis, preoperative superior vena cava pressure and preoperative oxygen saturation were found to be the independent predictor for postoperative mortality. There was also no significant difference in actuarial rate of freedom from late-occurring complications between eTCPC and ieTCPC groups. In the multivariate analysis, dominant right ventricle and preoperative SVC pressure were independent predictors for late-occurring complications. CONCLUSIONS: The clinical outcomes in patients who undergo eTCPC and ieTCPC appear to be excellent, with low mortality and morbidity rates in the midterm. ieTCPC may be a good option for TCPC cases with anatomical complexity such as apicocaval juxtaposition and separated hepatic vein drainage.

Impact of intrapulmonary-artery septation to pulmonary vein obstruction for two-lung Fontan.

OBJECTIVES: Patients with unbalanced pulmonary artery (PA) growth and decreased unilateral pulmonary circulation are considered unsuitable candidates for the Fontan procedure. Following our previous study on the utility of intrapulmonary-artery septation for patients with PA hypoplasia, we investigated its use in patients with pulmonary venous obstruction (PVO). METHODS: We recruited 42 patients who underwent intrapulmonary-artery septation for unilateral PA hypoplasia and/or PVO between 1998 and 2018 and classified them into no PVO or PVO group. We analysed overall survival, success of the Fontan procedure and data from catheterization and echocardiography. In PVO, we evaluated the functional lung area before the Fontan procedure and the relevance of this parameter to operative outcomes. RESULTS: The PVO and no-PVO group included 24 and 18 patients, respectively. One patient in the no-PVO and 6 patients in the PVO group died during follow-up; this difference was statistically significant (log-rank P = 0.040). In the no-PVO group, 15 (83%) patients achieved two-lung Fontan circulation. In the PVO group, 12 (50%) patients achieved two-lung Fontan circulation. Multivariate analysis revealed that functional lung area and shunt size [significantly larger in patients with functional lung area ≥50% in affected lung (P = 0.040)] were significant factors for successful two-lung Fontan procedure (P = 0.030). CONCLUSIONS: Intrapulmonary-artery septation may contribute to increase functional lung area after PVO release to establish two-lung Fontan circulation in patients with PVO who have unbalanced PA growth and/or decreased unilateral pulmonary circulation.

Cardioprotective effect of hyperkalemic cardioplegia in an aquaporin 7-deficient murine heart.

BACKGROUND: Hyperkalemic cardioplegia using St. Thomas' Hospital solution No. 2 (STH2) is commonly used to protect the myocardium during surgery. Mice deficient in the myocyte channel aquaporin 7 (AQP7) show significantly reduced glycerol and ATP contents and develop obesity; however, the influence of AQP7 on cardioplegia effectiveness remains unclear. METHODS: After determining the influence of ischemic duration on cardiac function, isolated hearts of male wild-type (WT) and AQP7-knockout (KO) mice (> 13 weeks old) were aerobically Langendorff-perfused with bicarbonate buffer, and randomly allocated to the control group (25 min of global ischemia) and STH2 group (5 min of STH2 infusion before 20 min of global ischemia, followed by 60 min of reperfusion). RESULTS: Final recovery of left ventricular developed pressure (LVDP) of WT and AQP7-KO hearts in the control group was 24.5 ± 12.4% and 20.6 ± 8.4%, respectively, which were significantly lower than those of the STH2 group (96.4 ± 12.7% and 92.9 ± 27.6%). Troponin T levels of WT and AQP-KO hearts significantly decreased in the STH2 groups (142.9 ± 27.2 and 219.9 ± 197.3) compared to those of the control (1725.0 ± 768.6 and 1710 ± 819.9). CONCLUSIONS: AQP7 was not involved in the protective efficacy of STH2 in this mouse model, suggesting its clinical utility even in complications of metabolic disease.

Complete repair with unifocalization of the only unilateral lung.

A boy with 22q11.2 deletion was diagnosed with pulmonary atresia with ventricular septal defect (PAVSD) and major aortopulmonary collateral arteries (MAPCAs). At 8 months, unifocalization of left MAPCAs and BT shunt was performed at another hospital. However, they occluded directly after surgery. An angiography revealed 2 MAPCAs supplying all segments of the right lung. Qp:Qs was 2.24. At 1 year 6 months, we performed VSD closure with unifocalization of the only right lung vascularity, using intraoperative PA flow study. We report a successful case of complete repair with unilateral lung in PAVSD and MAPCAs.

[Current Status of Thrombectomy Calls for Acute Ischemic Stroke for a Single Neurointerventionist in a Regional Hospital].

OBJECTIVE: The purpose of this study was to investigate the current status of thrombectomy calls for acute ischemic stroke for a single neurointerventionist in a regional hospital. METHODS: We retrospectively evaluated patients with thrombectomy calls for a neurointerventionist from January to November 2016 in our hospital, where a single board-certified neurointerventionist conducts endovascular interventions. Number, frequency, and time of thrombectomy calls were analyzed. Patients ineligible for revascularization were still used in analysis even though the neurointerventionist did not perform thrombectomy. RESULTS: Over 11 months(334 days), there were 105 calls, of which 48 were during duty hours and 57 during off-duty hours. The neurointerventionist was called once every 3.2 days in total, once every 4.7 days during duty hours, once every 5.7 days during off-duty hours of working days, and once every 6.2 days during holidays. Thrombectomies were performed in 37 cases(35%). Thrombectomies were performed once every 9.1 days and once every 2.8 calls. Twenty-four patients presented with ischemic stroke with large vessel occlusion, but they were determined to be ineligible for thrombectomy because of progressed ischemia in 7 patients, poor clinical condition in 7, or symptom recovery or recanalization in 10. Diagnoses of 42 patients who were not indicated for thrombectomy included ischemic stroke without major artery occlusion in 24 patients and intracerebral hemorrhage in 14. CONCLUSION: In a regional hospital with a single neurointerventionist, the frequency of thrombectomy calls was about once in every 3 days, and approximately half of them occurred during off-duty hours. A thrombectomy was performed about once every 9 days and about once every 3 thrombectomy-calls. Measures should be taken to reduce the burden on neurointerventionists in stroke centers, especially in understaffed institutes.

Synergistic Effects of Olaparib and DNA-damaging Agents in Oesophageal Squamous Cell Carcinoma Cell Lines.

BACKGROUND/AIM: Chemotherapy is an important first-line treatment for oesophageal squamous cell carcinoma (ESCC). However, there are few secondary options. Olaparib, a poly (ADP-ribose) polymerase (PARP) inhibitor, enhances the cytotoxicity of various anticancer drugs and has been used to treat advanced ovarian and breast cancers. This study examined the effect of olaparib on the cytotoxicity of anticancer drugs in ESCC cell lines. MATERIALS AND METHODS: ESCC KYSE70 and KYSE140 cells were grown in Dulbecco's modified Eagle's medium and treated with 5-fluorouracil (5-FU), cisplatin, docetaxel, doxorubicin, SN-38, or temozolomide without or with olaparib. RESULTS: Olaparib enhanced the cytotoxicity of all tested anticancer drugs and increased the effects of cisplatin, doxorubicin, SN-38, and temozolomide synergistically. These anticancer drugs caused the accumulation of phospho-histone H2AX Ser139 (γH2AX), a biomarker of DNA damage, and olaparib increased this accumulation. CONCLUSION: PARP inhibitors may potentiate the anticancer activity of DNA-damaging agents in ESCC patients synergistically.

Pediatric Case of Staphylococcus lugdunensis-Induced Infective Endocarditis at Bovine Jugular Vein.

A 2-year-old boy underwent repeat right ventricular outflow tract reconstruction (re-RVOTR) with a bovine jugular vein (BJV) graft. He presented with high fever on postoperative day 6. Blood and drainage effusion cultures were all positive for Staphylococcus lugdunensis and vancomycin was prescribed. Echocardiography showed vegetation at the BJV. Re-re-RVOTR was performed 51 days after re-RVOTR. In the operation, vegetation was adhered to the right-sided leaflet and three leaflets were degenerated. After complete BJV graft resection, an expanded polytetrafluoroethylene conduit with trileaflets was implanted. There was no sign of recurrent infection 8 months after the surgery.

Relationship between low response to clopidogrel and periprocedural ischemic events with coil embolization for intracranial aneurysms.

OBJECTIVES: Low response to antiplatelet drugs is one of the risk factors for ischemic events. We examined the influence of low response to clopidogrel on symptomatic ischemic events and new ischemic MRI lesions with endovascular intracranial aneurysmal coil embolization. MATERIALS AND METHODS: Between August 2010 and July 2013, 189 procedures in 181 consecutive patients who underwent endovascular coiling and received clopidogrel before treatment were investigated retrospectively. Platelet aggregation activity was examined by VerifyNow analysis. Low response to clopidogrel was defined as P2Y12 reaction units ≥230 in this study. Symptomatic ischemic complications within 30 days and postoperative new ischemic lesions on MRI-diffusion weighted imaging were evaluated. RESULTS: 66 of 189 (34.9%) cases were low responders to clopidogrel. Ischemic complications occurred in 2 of 66 (3.0%) low responders compared with 6 of 123 (4.9%) responders (p=0.72). A new high intensity spot larger than 5 mm was significantly more frequent in low responders (26 of 66; 39.4%) than in responders (26 of 121; 21.2%; p=0.01). On multivariate analysis, independent risk factors for larger new ischemic lesions were low response to clopidogrel, smokers, posterior location, and aneurysms with a larger neck. CONCLUSIONS: Low response to clopidogrel had little effect on clinical outcome although it increased asymptomatic large ischemic lesions in this cohort.

Results and current trends of multimodality treatment for infectious intracranial aneurysms.

The authors retrospectively reviewed their cases of infectious intracranial aneurysms and discuss results and trends of current treatment modalities including medical, neurosurgical, and endovascular. Twenty patients (10 males and 10 females; mean age 46 years) with 23 infectious aneurysms were treated by various treatment modalities during a 15-year period. Fifteen cases (75.0%) were caused by infective endocarditis. Eleven aneurysms (47.8%) were ruptured. Two aneurysms (8.7%) presented a mass effect and 7 (30.4%) were unruptured and asymptomatic. The average aneurysm size was 6.5 ± 4.8 mm (range 1-22 mm). The aneurysms were located in proximal cerebral circulation in 7 (30.4%) and distal in 16 (69.6%). Six (26.1%) aneurysms were treated surgically (5: trapping, 1: neck clipping), 10 (43.5%) endovascularly (7: trapping, 2: proximal occlusion, 1: saccular coiling), and the remaining 7 (30.4%) medically. Endovascular treatment was gradually increased with time. Medical and surgical treatments were continuously performed during the study period. Surgery was preferred for the patient with intraparenchymal hematoma or treated by bypass surgery. Three periprocedural minor complications occurred in endovascular treatment. There was one postoperative infarction with permanent deficit developed from surgical treatment. During the follow-up period (mean 28.8 months), none of the aneurysms presented a recurrence or rebleeding. Thirteen patients (65.0%) had favorable clinical outcomes (modified Rankin Scale: 0-2), although four (20.0%) had poor outcomes (modified Rankin Score: 5-6). A multimodal approach for the management of infectious aneurysms achieved satisfactory results. Endovascular intervention is a feasible and efficacious treatment option and surgical intervention is still an indispensable procedure.

The 'one and a half round microcatheterization technique' for stent-assisted coil embolization of intracranial aneurysm: technical case series.

BACKGROUND: Stent-assisted coil embolization is useful for wide-necked, large and giant aneurysms, and is effective for avoiding coil herniation. However, the mobility of the microcatheter is often restricted, resulting in deviated or unbalanced coiling. In order to prevent this insufficient coiling, the authors devised a method for microcatheterization, the 'one and a half round microcatheterization technique'. This technique is based on the formation of a one and a half round loop by the microcatheter along the aneurysmal wall. Furthermore, this technique can be supplemented with the double-catheter technique. METHODS: From July 2010 to July 2012, the authors used this technique for 20 aneurysms in 20 patients (6 men and 14 women; mean age 61.7 years). The one and a half round microcatheterization technique was used alone in 12 cases and was supplemented with the double-catheter technique in eight. The clinical and angiographic results were retrospectively evaluated. RESULTS: The average aneurysm size was 16.7 mm; 12 aneurysms (60%) were located at the internal carotid artery, 5 (25%) at the basilar artery and 3 (15%) at the vertebral artery. Immediate angiographic results showed complete obliteration in 6 aneurysms (30%) and residual neck in 10 (50%), leaving 4 residual aneurysms (20%). This technique was useful and acceptably safe for packing the aneurysmal sac entirely. During an average follow-up of 20.5 months, 13 of the 18 aneurysms (72%) were stable or had improved, although 3 (16%) required retreatment. CONCLUSIONS: The one and a half round microcatheterization technique provides dense coil packing for stent-assisted embolization of large or giant aneurysms.

[Systematic review of complications for proper informed consent (9) periprocedural complications of carotid artery stenting: a review article].

BACKGROUND: Carotid artery stenting(CAS)is a common procedure for the treatment of high surgical risk patients with carotid artery stenosis. Recent clinical study failed to show the non-inferiority of CAS to carotid endarterectomy(CEA)because of higher complication rates of CAS. However the result of a multicenter case study in Japan with tailored application of adequate devices including stents and protection devices revealed the safety of CAS in Japan. In this article the overall review in the previous reports of CAS are reviewed focusing on the complications and clinical outcome. METHOD: Five randomized controlled trials concerning CAS versus CEA and 14 case series of CAS were reviewed, and the rates of periprocedural complications of CAS including death, stroke, myocardial infarction, hypotension and bradycardia, cranial nerve palsy, major vascular injury, cholesterol crystal embolization and hyperperfusion syndrome were summarized. RESULT: Mortality within 30 days of procedures was 0.9%. The rate of any stroke was 6.0% from the five RCT results, but a recent 14-case series reported any stroke rate at 3-4% and severe stroke rate at 1-2% respectively. The rates of acute myocardial infarction, hypotension, and bradycardia were 1%, 4%, and 4-12% respectively. The rate of bleeding complication of the access root was about 2% and non-bleeding was 1-2%. Cholesterol crystal embolization occurred in 0.2%. Incidence of hyperperfusion syndrome occurred in 1.5%, and intracranial hemorrhage in 0.8%. CONCLUSION: Historically, the rapid improvement of devices and technical skills have contributed to the better clinical results. Also the lessons from complication cases have led to more appropriate indication and perfect protection to avoid adverse events. Therefore the rate of complication is always improving and those written in this article may not reflect the present real number. This article should be quoted with the previous reference as well as the newest data according to the operator's own experiences on taking informed consent.