A retrospective study on safety and efficacy of recombinant human soluble thrombomodulin to acute aortic dissection with disseminated intravascular coagulation.

OBJECTIVES: Recombinant human soluble thrombomodulin (rTM) has recently been used as a promising therapeutic natural anti-coagulant drug for disseminated intravascular coagulation (DIC). Here we investigated the safety and efficacy of rTM after aortic surgery in patients with acute aortic dissection (AAD). METHODS: A total of 316 patients diagnosed with AAD underwent emergent ascending aortic replacement or total arch replacement between 2010 and 2019. We retrospectively analyzed the clinical information of 62 patients with the Japanese Association for Acute Medicine's acute-stage DIC diagnostic criteria (JAAM criteria) with a score of ≥ 4. We assigned 62 patients to two groups, either non-rTM group (n = 29) or rTM group (n = 33). Patient characteristics, surgical procedures, and postoperative outcome data including coagulation function and the JAAM DIC score in both groups were collected. RESULTS: The decrease in the number of platelets was clearly suppressed on days 1-3 in the rTM group. On days 1-4, fibrin degradation product levels were upregulated in the non-rTM group but significantly downregulated in the rTM group. Five operative deaths occurred within 30 days postoperative (two [6.9%] in the non-rTM group vs. three [9.1%] in the rTM group). The JAAM DIC score showed a gradually improving trend from postoperative day 1 in the rTM group. CONCLUSIONS: Postoperative rTM administration for AAD may be a safe and promising novel treatment strategy for improving the JAAM DIC score.

Graft protective effects and donor-specific antibody suppression by CD4+CD25+Foxp3+ regulatory T cell induced by HMG-CoA reductase inhibitor rosuvastatin in a murine heart transplant model.

BACKGROUND: We previously demonstrated that the hydroxymethylglutaryl-CoA (HMG-CoA) reductase inhibitor (statins) play an important role in the regulation of alloimmune responses. However, little is known regarding the effects of statin on allograft protection or donor-specific antibodies (DSA). In this study, we investigated the graft-protective and immunomodulatory effects of rosuvastatin in a model of fully major histocompatibility complex-mismatched murine cardiac allograft transplantation. METHODS: CBA mice underwent transplantation of C57BL/6 (B6) hearts and received 50 and 500 µg/kg/day of rosuvastatin from the day of transplantation until seven days after the completion of transplantation. To confirm the requirement for regulatory T cells (Tregs), we administered an anti-interleukin-2 receptor alpha antibody (PC-61) to rosuvastatin-treated CBA recipients. Additionally, histological and fluorescent staining, cell proliferation analysis, flow cytometry, and DSA measurements were performed. RESULTS: CBA recipients with no treatment rejected B6 cardiac graft acutely (median survival time [MST], 7 days). CBA mice treated with 500 µg/kg/day of rosuvastatin prolonged allograft survival (MSTs, 77 days). Fluorescent staining studies showed that rosuvastatin-treated recipients had strong aggregation of CD4+Foxp3+ cells in the myocardium and around the coronary arteries of cardiac allografts two weeks after grafting. Flow cytometry studies performed two weeks after transplantation showed an increased number of splenic CD4+CD25+Foxp3+ T cells in rosuvastatin-treated recipients. The addition of rosuvastatin to mixed leukocyte cultures suppressed cell proliferation by increasing the number of CD4+CD25+Foxp3+ Tregs. Additionally, Tregs suppressed DSA production in rosuvastatin-treated recipients. CONCLUSION: Rosuvastatin treatment may be a complementary graft-protective strategy for suppressing DSA production in the acute phase, driven by the promotion of splenic and graft-infiltrating CD4+CD25+Foxp3+ Tregs.

Successful resection of a primary angiosarcoma of the azygos vein: A case report.

A 63-year-old woman was admitted to our department for the investigation of superior vena cava (SVC) syndrome. Computed tomography revealed an azygos tumor extending into the SVC. Video-assisted thoracic surgery (VATS) was performed to remove the distal end of the azygos vein in the left lateral position, followed by complete resection of the entire tumor under median sternotomy in the supine position. The histological diagnosis was a primary angiosarcoma of the azygos vein. The patient was discharged without any complications and is now alive and tumor-free 24 months after surgery. In addition, contrast-enhanced computed tomography revealed no graft occlusion in the two reconstructed brachiocephalic veins. Thoracoscopic surgery in the lateral position is useful for safe and reliable complete resection of a tumor arising from the azygos vein.

Placement of stent grafts with different calibers into the true and false lumens of anastomotic aneurysms after descending aortic replacement for aortic dissection.

Anastomotic aneurysms present as a life-threatening emergency after descending aortic replacement for aortic dissection. Thoracic endovascular aneurysm repair (TEVAR) has been performed since the early 2000s for complicated cases in which re-thoracotomy cannot be adopted. We report the case of a 57-year-old male patient, during a 5-year follow-up after descending aortic replacement for aortic dissection, developed aneurysm expansion around the false lumen on the peripheral side of the artificial graft. Considering the risk and the patient's desires, we opted to perform TEVAR with different calibers into the true and false lumens "modified kissing stents technique". His postoperative course was uneventful without any complications. This case highlights the utility of the modified kissing stents technique for anastomotic aneurysms after descending aortic replacement for aortic dissection using stent grafts with different calibers into the true and false lumens.

A successful case of patch angioplasty with bovine pericardium XenoSure® to the common femoral artery after endarterectomy.

INTRODUCTION AND IMPORTANCE: The number of patients with chronic limb-threatening ischemia has increased in recent years. Herein, we report a rare case of angioplasty with a bovine pericardial patch in a patient with severe stenosis of the common femoral artery. CASE PRESENTATION: We report a case of a 73-year-old female with intermittent claudication. Ankle-brachial index (ABI) measurements showed a significant decrease of 0.52 on the left, and angiography revealed total occlusion on the left common femoral artery (CFA). Considering additional skin incisions, postoperative wound infection, and potential graft sampling, endarterectomy of the left CFA and patch angioplasty with the bovine pericardium (XenoSure®) were performed. The operative computed tomography showed no stenosis and the ABI improved from 0.52 to 1.15. Additionally, no stenosis, calcification, or dilatation was observed during the follow-up one year after the operation. CLINICAL DISCUSSION: Various types of peripheral arterial repair were performed after endarterectomy. Autologous vein grafts and vascular prostheses are frequently used considering the background of each patient. Using bovine pericardium over other devices has several advantages, including no additional skin incisions to obtain the patches, resistance to infection, no oozing from the device itself, less bleeding from the suture site, and ease of hemostasis after the puncture under additional endovascular treatment. This case may be a good implication when deciding which device to use in complicated patients. CONCLUSION: This case provides valuable insight into successful patch angioplasty after endarterectomy without any complications, highlighting the utility of XenoSure® in the treatment of this disease.

Sex Differences in DeBakey Type I/II Acute Aortic Dissection Outcomes: The Tokyo Acute Aortic Super-network.

Background: Sex differences in the clinical presentation and outcomes of DeBakey type I/II (Stanford type A) acute aortic dissection (AAD) remain unclear. Objectives: The authors aimed to determine the impact of sex on the clinical presentation and in-hospital outcomes of surgically or medically treated patients with type I/II AAD. Methods: We studied 3,089 patients with type I/II AAD enrolled in multicenter Japanese registry between 2013 and 2018. The patients were divided into 2 treatment groups: surgical and medical. Multivariable logistic regression was used to examine the association between sex and in-hospital mortality. Results: In the entire cohort, women were older and more likely to have hyperlipidemia, previous stroke, altered consciousness, and shock/hypotension at presentation than men. Women had higher proportions of intramural hematomas and type II dissections than men. In the surgical group (n = 2,543), men had higher rates of preoperative end-organ malperfusion (P = 0.003) and in-hospital mortality (P = 0.002) than women. Multivariable analysis revealed that male sex was associated with higher in-hospital mortality after surgery (OR: 1.71; 95% CI: 1.24-2.35; P < 0.001). In the medical group (n = 546), women were older and had higher rates of cardiac tamponade (P = 0.004) and in-hospital mortality (P = 0.039) than men; no significant association between sex and in-hospital mortality was found after multivariable adjustment (OR: 0.95; 95% CI: 0.56-1.59; P = 0.832). Conclusions: Male sex was associated with higher in-hospital mortality for type I/II AAD in the surgical group but not in the medical group. Further research is needed to understand the mechanisms responsible for worse surgical outcomes in men.

Surgical treatment of papillary fibroelastoma of the pulmonary valve: a case report.

BACKGROUND: Cardiac papillary fibroelastoma (PFE) is a rare tumor, and especially rare when found on the pulmonary valve. CASE PRESENTATION: We report the case of a 70-year-old woman patient with a pulmonary valve PFE diagnosed incidentally during a follow-up of aortic regurgitation. Computed tomography and magnetic resonance imaging showed no suggestive signs of malignant tumors, and thrombus or myxoma was initially suspected. However, an initial transthoracic and transesophageal echocardiogram did not exclude the possibility of a malignant tumor attached to the wall of the pulmonary artery. Considering the embolization risk, we opted to perform tumorectomy, in which additional surgical procedures could then be conducted if intraoperative diagnosis showed a malignant tumor. Indeed, intraoperative findings showed the tumoral mass attached on the left semilunar cusp of the pulmonary valve, and intraoperative diagnosis of the tumor showed no malignancy. Planned tumorectomy was performed concomitantly with AVR. The pathologic examination of the removed tumor confirmed the diagnosis of PFE. Her postoperative course was uneventful without any sign of recurrence. CONCLUSION: This case highlights the difficulty of accurate diagnostic imaging and provides valuable insight into a successful surgical treatment of pulmonary valve PFE without any complications.

Primary malignant pericardial mesothelioma presenting with cardiac tamponade.

INTRODUCTION: Primary malignant pericardial mesothelioma is a rare tumor that is very difficult to diagnose. Furthermore, it is a lethal disease, because patients usually have progressed at the time of referral. PRESENTATION OF THE CASE: We report a 44-year-old man with primary malignant pericardial mesothelioma. He was referred to our hospital for the diagnosis and treatment of a massive pericardial effusion and huge tumor. Pericardiocentesis was performed, but we could not obtain definitive diagnosis, and the cardiac tamponade continued along with the signs/symptoms. He required surgical intervention for the diagnosis and treatment. After surgery, his signs/symptoms improved. He received adjuvant therapy, although he died 7 months after surgery. DISCUSSION: Primary malignant pericardial mesothelioma is a rare tumor. The most common signs and symptoms are related to constriction of the heart by the tumor and/or effusion. Even if the pericardial fluid specimen obtained by pericardiocentesis is negative for malignant cells, primary malignant pericardial mesothelioma should be included in the differential diagnosis. Because the malignancy is usually advanced at the time of diagnosis, it has been difficult to cure. Radiation and chemotherapy have been used in addition to surgery, but have been minimally effective. CONCLUSION: The outcome of our patient with pericardial malignant mesothelioma was dismal. The indications for surgical intervention should be carefully considered except for critical cases requiring alleviation of immediate life-threating conditions.

Surgical Treatment Strategy with Combined Cardiopulmonary Bypass for Renal Cell Carcinoma with Tumor Embolism Developed in Inferior Vena Cava.

OBJECTIVE: Renal cell carcinoma (RCC) with tumor thrombus in the inferior vena cava (IVC) presents surgeons with a technical intraoperative challenge because of the need for aggressive surgical management. In this study, we describe our method for surgical management with cardiopulmonary bypass (CPB) and investigate the long-term outcomes of RCC patients with and without CPB. METHODS: Fifteen patients with RCC underwent nephrectomy and IVC thrombectomy from May 2011 to December 2017. We retrospectively reviewed and analyzed the clinical course of all patients. Novick classification was used to assess the level of tumor thrombus extension into the IVC. Patient characteristics, surgical procedures, and postoperative outcome data in both groups were collected. RESULTS: Twelve patients were male and 3 were female, with an average age of 62.9 ± 10.9 years (range 46 to 82). The average operative times were 824 ± 335 minutes in the patients with CPB and 646 ± 162 minutes in those without CPB (P = .17). The average amount of intraoperative bleeding was 2125 ± 1315 ml in the patients with CPB and 3333 ± 1431 ml in those without CPB (P = .14). The same tendency was observed in patients of Novick levels 3 and 4. The mean observation period was 1061.4 days. No 30-day mortality was noted. There was no significant difference in all-cause survival between the patients with CPB and those without. CONCLUSIONS: We conclude that surgical management with CPB and circulatory arrest may be a viable and safe method of treatment for RCC patients.

Thoracic aortic endografts used to resect the left subclavian artery infiltrated by malignant tumours.

Endograft placement is a minimally invasive procedure used to repair thoracic aortic aneurysms. This technique is used for treating aneurysms and aortic dissections or ruptures, but it can also be applied for the resection of malignant tumours with vascular invasion. We describe the successful use of the thoracic endovascular aortic repair technique to remove a malignant tumour infiltrating the left subclavian artery in a 50-year-old man. The resection of the left subclavian artery infiltrated by thoracic malignant tumours may require temporary cardiopulmonary bypass, direct clamping of the aorta or extracorporeal circulation techniques. However, the off-label use of thoracic endovascular aortic repair avoids the need for these high-risk surgical techniques. After the surgical removal of the mass and combined aortic resection without complications, the patient was eligible to undergo chemotherapy/radiotherapy, thus improving his prognosis.

Surgical treatment of a huge hepatic artery aneurysm without revascularization-Case Report.

INTRODUCTION: Hepatic artery aneurysms (HAA) are rare and life-threatening. PRESENTATION OF CASE: We report a case of a 68-year-old man with a huge HAA diagnosed incidentally. Computed tomography showed a huge HAA (67-84 mm diameter). The patient underwent aneurysm resection and ligation of the common and proper hepatic arteries via laparotomy. Revascularization was not performed because intraoperative ultrasound showed pulsatile inflow to the left hepatic lobe. Postoperative cholecystitis and hepatic infarction were temporarily observed. Two months after the previous discharge, cholecystectomy was performed. DISCUSSION: A diameter ≥5 cm of HAA is thought to be rare in arterial aneurysm diseases. There is no consensus in the treatment policy and treatment is selected according to the patient's condition. In this case, we selected open surgery for this patient instead of endovascular surgery due to rupture risks, irregularity and narrowness of vessel structure, and prolonged irradiation-time. If revascularization is not performed at the time of resection, open surgery with cholecystectomy is capable of preventing postoperative cholangitis after resection of HAA, and should be taken into account even if collateral circulation can be confirmed. CONCLUSION: This case highlights the difficulty of managing HAA and provides insight into a successful surgical treatment of HAA without complete revascularization.

A case of an elderly man who required repeated repair of a ventricular septal defect and tricuspid rupture after blunt chest trauma.

Several cases of traumatic ventricular septal defect (VSD) have been reported. However, traumatic VSD complicated by tricuspid rupture is rare. We report a case of traumatic VSD with tricuspid rupture who required repeated repair of both conditions. A 69-year-old man was transferred to our hospital for emergent surgical repair of traumatic VSD and tricuspid rupture. Although emergent repair was performed, a new left-to-right shunt and moderate tricuspid regurgitation appeared during his postoperative course. A reoperation was performed 4 months after the first operation. The borders of the defect were very fibrotic and strong compared with those in the first operation. Surgical treatment of traumatic VSD should be postponed in hemodynamically stable patients. When emergent repair is performed, careful follow-up is necessary to diagnose new VSD.

Combined Aortic Resection and Stent Graft Insertion for Local Recurrence of Metastatic Lung Carcinoma Following Stereotactic Radiotherapy: A Case Report.

Stereotactic radiotherapy (SRT) is a useful treatment for malignant ling tumors. However, SRT is associated with complications such as high local recurrence rate and radiation-induced lung injury. Herein, we report a case of combined aortic resection for after SRT. An 82-year-old man underwent SRT for the metastatic lung carcinoma of rectal cancer at left lower lobe. Three years later, chest computed tomography showed local recurrence at the site of radiotherapy, with suspected invasion of the descending aorta. Thoracotomy was performed after metastatic lung carcinoma interpolation of a stent graft in the descending aorta. Because the tumor firmly adhered to the aorta, left lower lung lobe and aortic wall resection was performed. Pathological findings revealed fibrous hypertrophy and adhesion between the visceral pleura and aorta. As shown in our case, combined aortic resection and stent graft insertion is an effective minimally invasive and safe treatment for SRT-induced tissue damage.

[Investigation of rescued cases with cardiac rupture caused by blunt trauma].

The mortality of cardiac rupture by blunt trauma is so high that quick diagnosis and appropriate treatment are essential for saving patients. Based on 8 such cases rescued in our hospital and on 70 other rescued cases reported in Japan, we review its treatment strategy. Ultrasound examination, particularly focused assessment with sonography for trauma (FAST), was useful for diagnosing traumatic cardiac rupture. It was, however, impossible to detect the exact site of rupture before surgery. Three quarters of the rescued cases suffered from right cardiac rupture and more than 95% of those were treated successfully without extracorporeal circulation. All the cases with multiple cardiac rupture needed cardiopulmonary bypass or percutaneous cardiopulmonary support (PCPS) for their surgeries. And so did a quarter of the cases with left cardiac rupture. The standard treatment strategy seems to be as follows:to release cardiac tamponade as slowly as possible, to set up an extracorporeal circulation for surgery, and to repair the ruptured heart via median sternotomy.

[Comparative study between landiolol and amiodarone for therapeutic efficacy after open heart surgery].

Tachyarrhythmia, especially atrial fibrillation, remains as a common complication after open heart surgery and sometimes leads to fatal condition. Many reports showed that landiolol (ultra short-acting beta one blocker) and amiodarone were effective against postoperative atrial fibrillation (POAF). However, there were few comparative studies between these 2 drugs as prophylactic agents, and no report mentioned the therapeutic efficacy. Our study suggests that landiolol be the 1st choice for rate control of tachyarrhythmia because of easy dose adjustment and mild side effects. Amiodarone may be useful for the patients whose left ventricular function is poor.

The minimum coronary artery diameter in which coronary spasm can be identified by synchrotron radiation coronary angiography.

BACKGROUND: Coronary vasospasm is defined as a temporary, intense narrowing of the coronary conduit artery. It brings about ischemic chest pain and becomes one of the causes of myocardial infarction. Coronary spasms are divided into two categories. One is the coronary spasm of the conduit artery and the other is the coronary microvascular spasm. Although coronary spasms are diagnosed with the images of coronary angiography, microvascular spasms cannot be diagnosed because of the limitations of conventional angiographic systems. However, synchrotron radiation coronary angiography (SRCA) can identify coronary arteries down to 100 microm in diameter in the beating heart and 50 microm in arrested heart. AIM: The purpose of this study was to confirm whether microvascular spasms could be identified or not using SRCA, and then down that size identification was possible. METHODS: The Langendorff perfusion system with isolated rat hearts was employed. Krebs-Henseleit solution (KH solution) was used as a perfusate. 10mM of 4-aminopyridine (4-AP: a voltage-gated potassium channel blocker; spasm inducer) was added to the KH solution and maintained for 5 min. SRCA was performed at pre-, during and 10 min after cessation of the KH solution with 4-AP. Coronary spasms were defined as a temporal 75% reduction of coronary arterial diameter. RESULTS AND CONCLUSION: Multiple sizes of coronary arteries showed coronary spasms. The minimum stenosed coronary artery size was 100 microm. Since coronary microvascular spasms are seen in the arterioles (50-400 microm), coronary microvascular spasms may be diagnosed with the use of synchrotron radiation coronary angiography.

Cigarette-smoke-induced vasoconstriction of peripheral arteries: evaluation by synchrotron radiation microangiography.

BACKGROUND: Although cigarette smoking is thought to constrict peripheral vessels, details have not been clarified because of the limitation of spatial resolution in conventional X-ray angiography systems. Synchrotron radiation microangiography can identify small arteries down to 50 microm in diameter. METHOD AND RESULTS: Male Wistar rats (n=9) were made to smoke a cigarette using the modified Griffith snout exposure system. Angiography of the rat hind limb was performed before, during, and 15 min after smoking. Arteries were classified into 3 groups based on the pre-smoking diameter: Group S: <100 microm, Group M 100-200 microm, Group L: >200 microm). In Groups M and L, arteries were constricted with smoking (mean diameter 140-106 microm; p<0.001, 260-162 microm; p<0.00001, respectively), whereas no constriction was noted in Group S (82-83 microm). Constricted arteries in Groups M and L returned to pre-smoking levels at 15 min after cessation of smoking. CONCLUSION: The acute changes brought about by cigarette smoking in rat peripheral arteries could be identified by synchrotron radiation microangiography. Cigarette smoking exclusively constricted arteries greater than 100 mum in diameter, which means there is vessel-size dependency of the impairment.

[Bilateral uretero-common iliac arterial fistula with long term uretelal stent: a case report].

A 37-year-old man underwent Miles' operation and adjuvant irradiation therapy for rectum cancer in 1999. The patient suffered from bilateral ureteral stricture after the previous therapies. Bilateral double-J ureteral stents were inserted and exchanged at regular intervals. Four years after the start of ureteral stenting, he complicated with gross hematuria and dysuria. When the right double-J stent was exchanged, massive bleeding from external opening of urethra was observed. Retrograde pyelography showed right uretero-iliac arterial fistula. Since endovascular treatment with covered stents had failed, we performed right common iliac artery embolization and femoral-femoral artery bypass. Two days after the operation, gross hematuria developed again. When the left ureteral stent was exchanged, active bleeding from the external meatus of urethra was revealed. Angiography showed extravasation from left common iliac artery. We diagnosed left uretero-iliac arterial fistula. Although we tried endovascular treatment with covered stent that was made of artificial vessel graft and metallic stent, thromboembolism was occurred in the covered stent. Finally, right axillo-femoral artery bypass was indicated. The last treatment achieved long-term good control of uretero-arterial fistula. The present case shows that uretero-arterial fistula is a serious complication of long-term ureteral stenting, especially in the case of post pelvic surgery and irradiation.

High-frequency QRS potentials as a marker of myocardial dysfunction after cardiac surgery.

BACKGROUND: High-frequency QRS potentials are sensitive to myocardial ischemia. The aim of this study was to evaluate the usefulness of high-frequency QRS potentials as a marker of myocardial dysfunction after cardiac surgery. METHODS: Seventy patients undergoing coronary artery bypass grafting or heart valve surgery were involved. High-frequency QRS potentials were measured by signal-averaged electrocardiogram, and calculated as the root-mean-square voltage of the total QRS duration (RMST). The postoperative RMST was expressed as a percentage of the preoperative RMST. The mean RMST at 1 to 2 hours after removing the aortic cross-clamp was compared with the cardiac index, inotropic agents, and aortic cross-clamping time. The occurrence of ventricular tachycardia within 24 hours and the RMST at 2 postoperative days were also evaluated. Patients were divided into quartile groups from highest to lowest at postoperative RMST (groups 1, 2, 3, and 4, respectively, from maximum to minimum). RESULTS: In postoperative states, cardiac index significantly decreased in accordance with the RMST decrease in a stepwise manner, although there were no differences in cardiac index among the four groups preoperatively. Inotropic agents and aortic cross-clamping time increased as RMST decreased. A high rate of ventricular tachycardia within 24 hours and delayed RMST recovery at 2 postoperative days were seen in group 4. The curve of sensitivity and specificity showed that severe reduction (threshold, 35%) of RMST indicated low-output syndrome. CONCLUSIONS: The severe reduction of filtered high-frequency QRS potentials was related to myocardial dysfunction. Measurement of filtered high-frequency QRS potentials could become a useful, noninvasive, real-time monitor of myocardial dysfunction after surgery.

Thrombolytic therapy for delayed, in-hospital stroke after cardiac surgery.

Five patients who had delayed stroke after cardiac surgery underwent intraarterial administration of a fibrinolytic agent for thromboembolism (n = 4) or thrombosis (n = 1) of the cerebral artery. Complete recanalization of the occluded artery was obtained in 3 patients and partial recanalization in 2. Additional angioplasty for basilar artery stenosis was performed in 1 patient. No patients exhibited rebleeding into the pericardial space or wound bleeding. All patients survived with moderate or full functional recovery. Immediate cerebral angiography and local thrombolysis may improve functional outcome and survival in patients with postcardiotomy cerebral thromboembolism.