A Patient with Werner's Syndrome Who Underwent Aortic Valve Replacement through Minimally Invasive Cardiac Surgery.

Werner's syndrome (WS) is a genetic disorder presenting with premature senility. In the present study, we performed minimally invasive cardiac surgery (MICS)-aortic valve replacement (AVR) on a patient with Werner's syndrome who presented with aortic stenosis. The patient, a 49-year-old Japanese man, was brought to the emergency room with dyspnea during exercise. On echocardiography, severe aortic stenosis was found and surgery was planned. He had poorly controlled diabetes mellitus and underwent MICS-AVR to avoid the risk of sternal osteomyelitis, which resulted in a good outcome. The aortic valve had sclerotic changes and a genetic disease was suspected based on the onset of aortic stenosis at a young age, characteristic appearance, and various signs of aging. Genetic testing led to the diagnosis of WS.

A patient with Marfan's syndrome who developed an acute aortic dissection at 28 weeks of pregnancy treated with aortic root replacement.

The patient was a 31-year-old pregnant woman who gave birth to her first child by vaginal delivery 7 years ago. She was diagnosed with Marfan's syndrome based on physical findings; however, the condition was not diagnosed before the onset. The patient developed acute aortic dissection at 28 weeks of pregnancy. A cesarean section was first performed to save the patient's life; then, a total hysterectomy was performed to prevent the risk of postpartum hemorrhage. Furthermore, aortic root replacement was performed using a temporary mechanical valve. The patient and her child have survived without any complications.

New method of posterior scallop augmentation for ischemic mitral regurgitation.

We report a new method of posterior middle scallop (P2) augmentation for ischemic mitral regurgitation to achieve deep coaptation. First, P2 was divided straight at the center and partially detached from the annulus in a reverse T shape. A narrow pentagon-shaped section of pericardium was sutured to the divided P2 and annular defect. The tip of the pentagon was attached directly to the papillary muscle, thus creating a very large P2 scallop. A standard-sized ring was placed. We adopted this technique in 2 patients with advanced ischemic cardiomyopathy, and no mitral regurgitation was observed during a 1-year follow-up.

Seamless reconstruction of mitral leaflet and chordae with one piece of pericardium.

OBJECTIVES: Mitral valve repair is challenging when enough pliable mitral leaflets and chordae are not left intact because of extensive infective endocarditis or chronic sclerotic degeneration. For those cases, we developed a simple method to reconstruct defective leaflets and chordae en bloc with a piece of pericardium, and the mid-term results were evaluated. METHODS: From January 2009 to November 2013, 25 patients with the mean age of 63 (range 20-88) years underwent this operation. The causes of mitral regurgitation were infective endocarditis in 8, sclerotic degeneration in 8, leaflet dehiscence of previous repair in 2, mitral annular calcification in 3, rheumatic in 2 and congenital in 2. After complete debridement of infected or consolidated tissue, we reconstructed defective mitral leaflets and chordae en bloc with a piece of glutaraldehyde-treated autologous pericardium. To substitute posterior leaflet and chordae, the pericardium was trimmed into a narrow pentagonal shape. The pointed end was attached directly to the corresponding papillary muscle, basal side edges to remnant leaflets on both sides, and the base to the annulus. For anterior leaflet, the pericardium was trimmed into a triangular shape if the lesion was confined in the left or right half or into a double-triangle shape if the lesion involved whole anterior leaflet. The summit of triangle was fixed to corresponding papillary muscle, and the base to remnant anterior leaflet, thus reconstructing coaptation zone and chordae seamlessly. RESULTS: There was no hospital death, and mitral regurgitation at discharge was none or trivial in all patients. During 1-59 months (mean 12.7) of complete follow-up, death, infection or hemolysis was not observed. In one patient, mitral regurgitation recurred 8 months postoperatively because the fixation suture of the pericardium to the papillary muscle broke. The valve was re-repaired with re-attaching the leg of the pericardium. Regurgitation was less than moderate in all other patients. One patient with rheumatic lesion who underwent anterior leaflet repair and Maze operation suffered minor stroke 1 month postoperatively but fully recovered. CONCLUSIONS: Seamless reconstruction of leaflets and chordae with pericardium seemed promising to repair extensively destructed mitral valve.

[Can local administration of tranexamic acid reduce aspirin-induced bleeding in off-pump coronary artery bypass grafting( CABG) ?].

OBJECTIVES: We examined the effect of local administration of tranexamic acid( TA) on reducing aspirin-induced bleeding in off-pump coronary artery bypass grafting(CABG). METHODS: From July 2009 to January 2011, 88 cases with off-pump CABG were divided into 4 groups:group C including 19 cases without preoperative aspirin or local administration of TA, group A including 23 cases with preoperative aspirin alone, group T including 19 cases with local administration of TA alone, and group AT including 27 cases with both preoperative aspirin and local administration of TA. RESULTS: The bleeding volume after 24 hours in group A was significantly larger than that in group C(p=0.0085). The bleeding volume in group AT was significantly smaller than that in group A (p<0.0001), and the bleeding volume in group T was also significantly smaller than that in group C (p=0.0054). There was no significant difference between group T and AT. CONCLUSIONS: The use of local administration of tranexamic acid indicated the reduction of postoperative bleeding even in patients with preoperative aspirin use.

Perioperative use of a beta blocker in coronary artery bypass grafting.

OBJECTIVES: Atrial fibrillation after cardiac surgery is associated with increases in the risk of complications, length of intensive care unit stay, and cost of care. Beta blockers are effective for controlling myocardial ischemia and arrhythmia and suppressing inflammatory cytokines. The purpose of this study was to examine the effect of administrating a short-acting beta-adrenoceptor antagonist, landiolol, on postoperative atrial fibrillation. METHODS: 136 patients undergoing off-pump coronary artery bypass grafting were single-blindly assigned randomly to landiolol (n = 68) and non-landiolol (control, n = 68) groups. In the landiolol group, the beta blocker was administered from the beginning of the operation until postoperative day 2. The primary endpoint was the incidence of atrial fibrillation until postoperative day 7, and the secondary endpoints were the postoperative levels of troponin I, creatine kinase MB-isoenzyme, and C-reactive protein. RESULTS: The incidence of atrial fibrillation was significantly lower in the landiolol group compared to the control group (13/68, 19% vs. 25/68, 37%, p = 0.02, logrank test). Landiolol also significantly reduced the postoperative peak C-reactive protein level compared to the control group (132 ± 55.4 vs. 161 ± 50.9 mgcL(-1), p = 0.004). CONCLUSION: Low-dose continuous infusion of landiolol reduced the incidence of postoperative atrial fibrillation, and significantly suppressed inflammation.

[Efforts to achieve anastomosis forms in coronary artery bypass grafting; cuff-like and skirt-like anastomoses].

As the type of anastomotic site is considered to be one of the decisive factors for graft-patency in coronary artery bypass grafting(CABG),our aim is to achieve anastomosis forms that potentially promote long-term graft-patency rates. When an arterial graft is used, side-to-side anastomosis is performed, with its incision length being longer than that of the coronary artery, to achieve a cuff-like anastomosis form. When a vein graft is used, on the other hand, it is incised shorter than the coronary artery to achieve a skirt-like anastomosis form instead of a purse-like one. It is thus expected that reliable anastomosis forms can be observed in postoperative angiography.

[The usefulness of COPD questionnaire for screening COPD subjects].

To evaluate the usefulness of the COPD questionnaire of the International Primary Care Airways Group (IPAG) for screening the subjects with COPD in a given cohort, the questionnaires were given to subjects aged 40 or older, regardless of smoking habit at a general health check-up program in 4 institutions (Miyagi, Osaka, Okayama and Fukuoka) of the Japan Anti-tuberculosis Association (JATA) prefectural branch from April 1, 2007 to March 31, 2008. The questionnaires scores of 11,166 participants were collated with their FEV1/FVC, with their agreement. The prevalence of cases at high-risk of COPD receiving a score of 17 or more was 27.5%, and airflow limitation defined as FEV1/FVC < 70% was found in 6.5% among these cases, i.e. 2.7% among all subjects. The area under the curve of the receiver operating characteristic (AUC-ROC), sensitivity, and specificity were 0.755, 0.666, and 0.736, respectively. Airflow limitation was observed more frequently in those older than 59, more than 24 pack-years, and frequent wheezes but not in those of cough affected by weather, sputum in the morning, and allergies. Among 4 institutions, sensitivities of airflow limitation varied from 0.581 to 1.000 and these were remarkably elevated to 0.702 and more by excluding the subjects with P x Y0-14. This questionnaire seemed to be effective using a cut-off level of 17 for screening cases at high risk of COPD.

Phylogenetic analysis of caprellid and corophioid amphipods (Crustacea) based on the 18S rRNA gene, with special emphasis on the phylogenetic position of Phtisicidae.

Members of the amphipod suborder Caprellidea exhibit degenerated abdomens and pereopods 3 and 4. Some genera of Podoceridae (Gammaridea, Corophioidea) such as Dulichia also show reduced abdomens and pereopods and thus are generally regarded as a sister group of the Caprellidea. In addition, one of the caprellid families, the Caprogammaridae, exhibits abdominal segments that are similar to those of the podocerids, as well as rudimentary pereopods 3 and 4, which are more consistent with those of other caprellids. Therefore, an evolutionary scheme has been suggested on the basis of the gradual degeneration of the pereopods and abdomen: [Dulichia, (caprogammarids, caprellids)]. However, the Phtisicidae (Caprellidea) contradict this hypothesis because they exhibit well-developed pereopods 3 and 4, along with degenerated abdomens. Therefore, previous studies have suggested that the Phtisicidae and other caprellids may be polyphyletic. We examined the phylogenetic position of the Phtisicidae and other caprellid amphipods, using 18S rRNA gene sequence data. The results strongly indicate that the Phtisicidae and other caprellid families form a monophyletic clade. However, a close phylogenetic relationship among Dulichia (Corophioidea) and taxa belonging to the Caprellidea was not definitively supported. This study is the first to use molecular data to investigate the phylogenetic relationships among the Caprellidea.

Massive pulmonary embolism after off-pump coronary artery bypass surgery.

An 88-year-old woman developed an acute massive pulmonary embolism after off-pump coronary artery bypass surgery. She experienced dyspnea while walking on the sixth day after operation. Her chest radiograph showed pleural effusion. Initially, she was treated for heart failure due to bypass graft occlusion. A repeat echocardiogram revealed enlargement of the right ventricle. Multislice computed tomography showed a massive embolus in the pulmonary artery. Surgical embolectomy was performed, and her postoperative course was easy. Recently, the incidence of pulmonary embolism in Japanese people has been rising. In addition, widespread implementation of off-pump coronary artery bypass compromises the protective effect against pulmonary embolus after cardiac surgery. Although the incidence of pulmonary embolism after coronary artery bypass surgery is still low in Japan in comparison to that in Western countries, prophylaxis against pulmonary embolism after off-pump coronary artery surgery is becoming more important.