Removal of a left ventricular thrombus complicated by cardiac sarcoidosis using a 3D microscope system.

A woman in her 60s was brought to the previous hospital with respiratory distress. She was referred for the treatment of severe cardiac dysfunction and a mobile mass in the left ventricle. Echocardiography revealed the mass to be of 20×11 mm in size, mobile and slightly attached to the left ventricle by a stalk. As MRI had already revealed a small cerebral infarction, we have decided to perform emergency thrombectomy of the left ventricle. As the left ventricular contractility was diffusely impaired, we were able to remove the mass without any residuals using a transseptal approach without a left ventricular incision using a three-dimensional microscope system. The pathological diagnosis of the mass was thrombus, and subsequent close examination led to the diagnosis of cardiac sarcoidosis. We report the surgical technique and removal of a left ventricular thrombus complicated by cardiac sarcoidosis.

[Ruptured Thoracic Aortic Aneurysm Treated with Total Arch Replacement and Direct Transaortic Thoracic Endovascular Aortic Repair].

Open stent grafting is an effective technique in surgery for treating-ruptured aortic aneurysms in the distal aortic arch, but it is not always applied as it depends on the shape of the aneurysm. In this case, the aneurysm was long in the distal aortic arch and sharply angulated into the descending aorta;thus, it was anticipated that an off-the-shelf open stent graft would not cover the ruptured area. Therefore, we used a stent graft device for thoracic endovascular aortic repair as an open stent and succeeded in saving the patient's life.

[Distal Anastomosis with Pleural Flap Wrap for Ruptured Acute Aortic Dissection].

A 69-year-old woman developed back pain was brought to our hospital. She was diagnosed with acute Stanford type B aortic dissection, and had a history of ascending aortic replacement for acute Stanford type A aortic dissection at another hospital 10 years before. In three days after admission, enhanced computer tomography (CT) revealed ruptured aortic dissection at the distal arch. Total aortic arch replacement was performed using the frozen elephant trunk technique. The Dacron polyester fabric prosthesis and aorta were anastomosed using the modified turn-up method at the distal anastomosis. Due to the fragility of the oesophageal side, the pleural flap was detached with the surrounding fatty tissue and transection was performed from the elephant trunk to the intima, adventitia, pleural flap, and felt strip. The use of an autologous pleural flap is a simple and effective method for controlling bleeding in a ruptured aortic dissection and for the distal anastomosis of fragile adventitia.

Preoperative diagnosis of knee cartilage, meniscal, and ligament injuries by magnetic resonance imaging.

PURPOSE: The purpose of the study was to report on the current accuracy measures specific to 1.5-Tesla MRI of the knee in the patient population prone to injuries of the anterior cruciate ligament (ACL), the menisci, and the articular cartilage. METHODS: We accrued patients between January 2018 through August 2021 who underwent a preoperative MRI and were diagnosed with an articular cartilage injury either due to unevenness of articular cartilage in T2-weighted sequences or due to the irregularity of subchondral bone in T1-weighted sequences. All patients were treated arthroscopically. Sensitivity, specificity, and accuracy were calculated for the detection of ACL, meniscus, and cartilage injuries. A P-value of < 0.05 represented statistical significance. RESULTS: One-hundred and forty-seven cases which included 150 knee joints were enrolled in this study. The mean age at the time of surgery was 42.9 years-old. The sensitivity in the diagnosis of ACL injuries was significantly greater than that in the diagnosis of cartilage injuries (P = 0.0083). The ratios of the equality of operative indication in 6 recipient sites were found to be between 90.0% and 96.0%. The diagnostic critical point was within a 1 cm in diameter. CONCLUSION: The diagnostic sensitivity in cartilage injuries was significantly lower than ones of ACL and meniscal injuries. The ratios of the equality of operative indication was determined to be between 90.0% and 96.0%, if we consider the unevenness of articular cartilage or the irregularity of subchondral bone. LEVEL OF EVIDENCE: Level III, Prospective diagnostic cohort study.

Intraoperative Acoustic Evaluation of Living Human Knee Cartilage-Comparison with Respect to Cartilage Degeneration and Aging.

OBJECTIVE: The objective of the study was to evaluate the mechanical properties of living human knee cartilage using our ultrasonic device, and to compare the measurements with respect to cartilage degeneration and aging. DESIGN: A total of 95 knees which had undergone arthroscopic knee surgery, from 88 patients, were included in the study, with informed consent. All procedures were reviewed and approved by the ethical committee of our hospital. In the study group, there were 41 men, 47 women, 39 right knees, and 56 left knees. The conditions primarily included knee osteoarthritis and anterior cruciate ligament rupture. The mean operative age was 44.1 years old (range = 10-83). We compared mechanical properties of the knee cartilage with respect to aging and gender, in comparison with normal cartilage. A P value of <0.05 represented statistical significance. RESULTS: In the context of the International Cartilage Repair Society (ICRS) classification of cartilage degeneration (grade 0-3), the signal intensity in grade 0 was significantly larger than that in grade 1, 2, or 3. The thickness in grade 0 was significantly higher than that in grade 1, 2, or 3. Normal cartilage in older women had the lowest signal intensity and the least cartilage thickness among all the groups. CONCLUSION: The ultrasonic system we developed was able to detect early degenerative changes in living cartilage in knees. The lowest signal intensity and least cartilage thickness in normal cartilage among older women were correlated to a large prevalence of knee osteoarthritis in women. LEVEL OF EVIDENCE: Level IV, case series.

Mosaicplasty With High Tibial Osteotomy for Knee Subchondral Insufficiency Fracture Had Better Magnetic Resonance Observation of Cartilage Repair Tissue Scores With Less Bone Marrow Edema and Better Plug Union and Less Plug Necrosis Compared With Mosaicplasty Alone.

PURPOSE: To determine the magnetic resonance imaging (MRI) findings after mosaicplasty (MOS) for knee subchondral insufficiency fracture (SIFK), and to analyze the relationship between MRI findings and clinical outcomes. METHODS: We retrospectively reviewed the cases of consecutive patients who underwent MOS for SIFK with/without high tibial osteotomy (HTO) between January 1998 and December 2015. The MRI findings at 12 months after the surgery were assessed by the modified magnetic resonance observation of cartilage repair tissue (MOCART) score to determine the degree of bone marrow edema (BME), plug union, and plug necrosis. The clinical outcomes were assessed by Lysholm score to clarify the minimal clinically important difference (MCID) and patient acceptable symptom state analysis. RESULTS: In total, 58 patients (17 men and 41 women) were enrolled in this study. Among them, 30 knees were treated by MOS alone and 28 knees were treated by MOS with HTO. The MOCART scores of patients who received MOS alone were significantly lower in BME score (P = .0060), plug union score (P = .0216), and in plug necrosis score (P = .0326) than patients who received MOS with HTO. BME lesion was less likely to persist among elderly (odds ratio 1.20, P = .0248) and female (OR 41.8, P = .0118) patients. The MCID of Lysholm score was 6.6 in MOS alone and 8.4 in MOS with HTO cases, but there were no significant association between MRI findings and the postoperative Lysholm score. CONCLUSIONS: The MOS with HTO cases had better MOCART scores with less BME, better plug union, and less plug necrosis compared with MOS alone cases. Female and older patients had better resolution of BME, but there was no significant correlation between MRI findings and the postoperative Lysholm score. All cases in both groups showed improvement of Lysholm score exceeding MCID; thus, MOS may be effective as a joint preserving surgery for SIFK. LEVEL OF EVIDENCE: Level IV, clinical case series.

The Oral Administration of Highly-Bioavailable Curcumin for One Year Has Clinical and Chondro-Protective Effects: A Randomized, Double-Blinded, Placebo-Controlled Prospective Study.

Purpose: The purpose of this study was to determine the clinical and chondroprotective efficacy and safety of orally administered Theracurmin in patients who underwent mosaicplasty for knee chondral or osteochondral diseases over 12 months of treatment. Methods: We enrolled 50 patients, older than 20 years of age, who underwent mosaicplasty for their knee joint diseases. Theracurmin at 180 mg of curcumin per day or placebo was administered orally every day for 12 months. Because 7 patients dropped out of the study, 43 patients were examined; they included 14 men and 29 women and 24 right and 19 left knees. The mean operative age was 59.5 years (range, 24-84 years). We evaluated the Japanese Orthopaedic Association knee osteoarthritis score (JOA), visual analog scale (VAS), and Japanese Knee Osteoarthritis Measure (JKOM) as clinical symptoms; T2 mapping values using magnetic resonance imaging as an indication of the chondroprotective effect; and blood concentration of curcumin at 0, 3, 6, and 12 months after the operations. We performed intraoperative acoustic evaluation of articular cartilage as a measure of chondroprotective effect during the operations and second-look arthroscopy. Results: The JOA, VAS and JKOM at 3, 6, and 12 months were significantly better than those during the preoperative period. However, the values of JOA, VAS and JKOM and T2 mapping were not significantly different between the Theracurmin and placebo groups. The blood concentration of curcumin in the Theracurmin group was significantly higher than that in the placebo group at 3, 6, and 12 months after the operations. Cartilage stiffness and surface roughness were significantly better in the Theracurmin group than in the placebo group at second-look arthroscopy. Conclusions: The oral administration of Theracurmin for 1 year demonstrated significantly better chondroprotective effects and no worse clinical effects and adverse events than the placebo. Level of Evidence: Level I, double-blinded, placebo-controlled, prospective study.

The effects of alendronate on the suppression of bone resorption and the promotion of cartilage formation in the human mosaicplasty donor site: A randomized, double-blind, placebo-controlled prospective study.

BACKGROUND: We previously reported that early alendronate administration accelerated bone formation and improved the quality of repaired cartilage in the donor site in rabbits. To investigate whether alendronate administration has effects in humans similar to those observed in rabbits. METHODS: The study cohort included 35 patients over the age of 12-years old who underwent mosaicplasty without osteoporotic therapy from March 2011 to October 2012. The donor sites were medial or lateral in the patellofemoral joint. Placebo (P) or Bonalon containing 35 mg of alendronate (A) was administered orally every week for 8 weeks. The cohort comprised 15 male and 20 female, including 14 right and 21 left knees. The mean age at the time of surgery was 57.1 years. Bone formation was examined using computer tomography and lateral knee radiography, and cartilage formation was examined using magnetic resonance imaging (MRI), second-look assessment, and intraoperative acoustic evaluation. The clinical outcomes were assessed using the Japanese Orthopaedic Association knee score and visual analog scale (VAS). Bone and cartilage formation in the donor site and clinical outcomes were assessed at 3, 6, and 12 months after mosaicplasty. RESULTS: The ratio of TRAP-5b in group A was significantly smaller than that in group P at 2 and 8 weeks after mosaicplasty. The extent of bone formation in the donor sites in group A was significantly greater than that in group P at 3 and 6 months after mosaicplasty. Cartilage formation did not differ significantly between the two groups as determined by MRI, macroscopic assessment, and intraoperative acoustic evaluation. Clinical outcomes did not differ significantly between the two groups, and no negative clinical outcomes were observed. CONCLUSION: Early alendronate administration accelerated bone formation but not cartilage formation in the mosaicplasty donor site in humans.

[Florida Sleeve Technique Concomitant with Total Aortic Arch Replacement].

A 73-year-old man with chest pain was brought to our hospital. He was diagnosed with acute myocardial infraction (AMI) by coronary arteriogram and underwent emergent intervention. Enhanced computer tomography( CT) revealed thoracic aortic aneurysm extending from sinus of Valsalva to proximal aortic arch. Fifty days after the onset of AMI, we performed valve-sparing aortic root replacement with the Florida sleeve technique, total aortic arch replacement and coronary artery bypass grafting. Post operatively, the patient's recovery went well without any complications. In subsequent CT, sinus of Valsalva was shrunk from 47 mm to 38 mm. The Florida sleeve technique is simple, effective and could reduce surgical risks.

Intra-Articular Injections of Curcumin Monoglucuronide TBP1901 Suppresses Articular Cartilage Damage and Regulates Subchondral Bone Alteration in an Osteoarthritis Rat Model.

OBJECTIVE: Curcumin monoglucuronide (TBP1901) is highly water soluble and can convert to free form curcumin, which has pharmacological effects, on intravenous administration. This study aimed to investigate the effectiveness of TBP1901 intra-articular injections in an osteoarthritis (OA) rat model. METHODS: Sixty-four male Wistar rats (12 weeks old) who underwent destabilized medial meniscus (DMM) surgery were randomly separated into the TBP1901 injection or saline solution (control) injection group. They were sacrificed at 1, 2, 6, or 10 weeks postoperatively (weeks 1, 2, 6, and 10; n = 8 for each group). TBP1901 (30 mg/mL) or saline solution of 50 µL was injected into the knee joints twice a week during weeks 1 and 2 to investigate the effects in the acute phase of posttraumatic (PT) OA or once a week during weeks 6 and 10 to investigate it in the chronic phase of PTOA. Histology, immunohistochemistry, and micro-computed tomography were performed to evaluate the changes in OA. RESULTS: TBP1901 injections significantly reduced synovial inflammation at weeks 1 and 2, and tumor necrosis factor-α expression in the articular cartilage at week 6. The TBP1901 injections also significantly suppressed articular cartilage damage, subchondral bone (SB) plate thickening, SB plate perforation, and osteophyte formation at week 10. CONCLUSIONS: TBP1901 intra-articular injections suppressed synovial inflammation in the acute phase of PTOA in DMM rats. In the chronic phase, TBP1901 suppresses articular cartilage damage and regulates SB plate changes.

[The Mid-term Results of Transapical Transcatheter Aortic Valve Implantation for Aortic Stenosis].

We aimed to evaluate the results of transapical transcatheter aortic valve implantation (TAVI) for aortic stenosis. Thirty patients who had aortic stenosis and underwent transapical TAVI between 2016 and 2020 were enrolled. Medical records were reviewed, and the following data were retrieved and analyzed:basic demographic data, and intraoperative data and postoperative outcomes. Mean age was 85.8 years. There were 3 intraoperative complications (1 apex bleeding, 1 coronary stenosis and 1 mitral regurgitation). Extracorporeal membrane oxygenation was initiated due to unstable hemodynamics in two patients. One patient was converted to mitral valve replacement due to severe mitral regurgitation. There were 2 in-hospital complications (1 with sick sinus syndrome and 1 with cerebral infarction). One patient died of cerebral infarction and eventually, the 30-day mortality was 3%. Median observational period was 1.3 years. Three-year survival was 87.3%. Left ventricular ejection fraction increased by six months after the procedure and then, reached plateau. Left ventricular mass index decreased constantly throughout the observational period. Both parameters at one year after the procedure were significantly higher than preoperative ones. In conclusion, survival after transapical TAVI was favorable because of the low critical complication rate. Both left ventricular functional improvement and reverse remodeling were obtained.

Long-Term Survivorship and Clinical Outcomes of Osteochondral Autologous Transplantation for Steroid-Induced Osteonecrosis of the Knee.

OBJECTIVE: Treatments for steroid-induced osteonecrosis of the knee remains challenging, and there has not been sufficient evidence to support joint preservation surgery. This study evaluated long-term outcomes of osteochondral autologous transplantation (OAT) for steroid-induced osteonecrosis of the knee. DESIGN: This retrospective case series included patients who underwent OAT for steroid-induced osteonecrosis of the knee from 1998 to 2008. The survivorship and need for secondary surgery were evaluated, and the clinical outcome was evaluated with the International Knee Documentation Committee (IKDC) subjective score. Preoperative and final Kellgren-Lawrence (KL) grade of the femorotibial and patellofemoral joints were individually evaluated. RESULTS: Fourteen knees of 10 patients whose mean age was 32.5 (95%CI 26.4-38.6) years were included and followed for 14.0 (12.4-15.7) years. The mean lesion size of 6.9 (5.3-8.5) cm2 was repaired using 4 median (minimum 2, maximum 5) osteochondral plugs. No revision surgeries were performed for transplanted osteochondral plugs. The IKDC subjective score improved from 32.9 (24.5-41.3) to 74.2 (61.9-88.5) (P < 0.001). Knee flexion was improved at the final follow-up, and Seiza sitting was finally possible in 9 knees in 7 patients. Although the osteoarthritic change did not progress in femorotibial joint, patellofemoral joint showed early osteoarthritic changes at the final follow-up (mean KL grade: 0.8 [0.5-1.1]). CONCLUSIONS: Prosthetic joint replacement was successfully avoided for at least the first decade by OAT in young patients with steroid-induced osteonecrosis of the knee. The progression of KL grade of the patellofemoral joint is of concern.

[Giant Left Atrial Myxoma Complicated with Hemorrhagic Cerebral Infarction].

A 48-year-old woman developed paralysis of the left upper limb and dysarthria. Two days later, she was admitted to a local hospital due to no improvement of symptoms. Brain magnetic resonance imaging showed acute hemorrhagic cerebral infarction in the left nucleus basalis. Echocardiography demonstrated a large left atrial mass in the left atrium, shuttling between the left atrium and the left ventricle and moderate mitral regurgitation. Then, she was transferred to our hospital for surgery. Five days after the initial symptoms, resection of the left atrial mass was performed under total cardiopulmonary bypass. First, heparin sodium, and then nafamostat mesilate were used as intraoperative anticoagulation treatment. The left mitral mass was removed via an atrial septal incision and the defect was repaired using a bovine pericardium. The mitral valve was intact and there was no regurgitation. The mass was immunohistologically diagnosed as myxoma. Postoperative brain computed tomography scans demonstrated no exacerbation of the cerebral infarction. She was discharged 13 days after surgery without neurological symptoms.

[Missing Floating Mass in the Ascending Aorta;Report of a Case].

A 65-year-old man, with a history of hypertension, presented with dizziness and emesis and was admitted to a local hospital. He was a moderate smoker, but he did not take any hormone-based medication. Magnetic resonance imaging showed scattered cerebral infarction in the bilateral cerebral hemisphere and right cerebellar hemisphere. There were no abnormal findings in Holter monitor and echography of heart, carotid artery, and leg vein and then, antiplatelet therapy was initiated. After that, both computed tomography and magnetic resonance imaging demonstrated a floating pedunculated mass in the ascending aorta measuring 10×8×14 mm. He was admitted to our hospital 15 days after the symptom onset. Laboratory tests including immunological and coagulation studies were within normal. Computed tomography showed on the second day of the admission that the mass spontaneously disappeared, thus canceling the schedule of surgery. He received an oral anticoagulant and discharged uneventfully. During a follow-up period of 6 months, there is no recurrence of the thrombus in the aorta and thromboembolic events.

[Rapid Expansion of Distal Aortic Arch Aneurysm with the Short Elephant Trunk;Report of a Case].

A 78-year-old female patient was introduced to our hospital with chief complaint of massive hemoptysis. She had a history of total arch replacement using a short elephant trunk for acute Stanford type A aortic dissection 3 years before. A contrast-enhanced computed tomography (CT) revealed kinking of the short elephant trunk and distal aortic arch aneurysm which caused aortobronchial fistula. She was treated by emergency thoracic endovascular aortic repair and long-term administration of antibiotics. Three years later, distal aortic arch aneurysm disappeared by CT and there was no recurrence of hemoptysis. This is the aortic aneurysm was considered to be caused by the short elephant trunk.

[Surgical Results for Left Ventricular Thrombus Formation after Myocardial Infarction].

We aimed to review the surgical results of left ventricular restoration for left ventricular thrombus after myocardial infarction. A retrospective study was conducted on 5 patients who underwent thrombus removal and left ventricular restoration for left ventricular thrombus after myocardial infarction. Two patients were in an acute phase of myocardial infarction, and 3 in a chronic phase. Cerebral infarction occurred in 3 patients preoperatively. Median observational period was 1.0 year. Left ventricular thrombus removal with septal anterior ventricular exclusion technique was performed. Concomitant procedure included 3 coronary artery bypass graftings and 1 left ventricular apex ablation. There was no perioperative bleeding event. The 30-day mortality occurred in 1 patient. There has been no systemic embolic complication, left ventricular dysfunction, nor recurrence of left ventricular thrombus during the observational period. The postoperative left ventricular volume reduced in 3 of the 4 survivors. The left ventricular ejection fraction increased postoperatively in 3 of the 4 survivors. In conclusion, the septal anterior ventricular exclusion technique is an effective method for controlling perioperative bleeding, removing left ventricular thrombus completely, and preventing a recurrence of left ventricular thrombus and systemic embolism. This procedure also contributed to reducing the left ventricular volume, resulting in the improvement of the left ventricular function.

Surgical Technique and Clinical Outcomes of Osteochondral Autograft Transplantation for Large Osteonecrotic Lesions of the Femoral Condyle With Residual Normal Cartilage: The Eyeglass Technique.

BACKGROUND: Osteochondral autograft transplantation (OAT) is usually performed for a defect that is <400 mm2 because of the limitations of autografts. PURPOSE: To present the surgical technique and clinical outcomes of OAT using the eyeglass technique for large osteonecrotic lesions of the femoral condyle (LOFs) (>400 mm2) with residual normal cartilage. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Cases (group 1) included 15 patients (18 knees) who underwent OAT using the eyeglass technique for LOFs with residual normal cartilage, while controls (group 2) included 11 patients (11 knees) who underwent OAT using the standard technique for small osteonecrotic lesions of the femoral condyle (≤400 mm2). Clinical outcomes were evaluated preoperatively and at the final follow-up (group 1, 56 months; group 2, 48 months) according to the International Knee Documentation Committee (IKDC) objective grade, the IKDC subjective score, and the Japanese Orthopaedic Association (JOA) score. RESULTS: The mean lesion size was 685 mm2 in group 1 and 230 mm2 in group 2. Patients in group 1 had postoperative scores equivalent to those in group 2. The postoperative IKDC subjective scores in group 1 (mean, 86.9) and group 2 (mean, 87.0) showed no significant difference at the final follow-up (P = .653). For postoperative IKDC objective grades, 83.3% of group 1 and 81.8% of group 2 were graded as "nearly normal" or better, and no significant intergroup difference was found for the IKDC objective grade (P = .989). Also, no significant intergroup difference was found for the postoperative JOA score (group 1, 93.9; group 2, 81.4; P = .480). Nine second-look arthroscopic procedures were performed in group 1 compared with 4 in group 2, and all patients had plugs that were graded as "nearly normal" or better by the International Cartilage Repair Society classification system. CONCLUSION: The postoperative results of patients who underwent OAT using the eyeglass technique for large osteonecrotic lesions (>400 mm2) were equivalent to the results of patients who underwent OAT using the standard technique for small osteonecrotic lesions (≤400 mm2).

The interference with transapical transcatheter aortic valve implantation by the anterior chordae tendineae preserved at previous mitral valve replacement.

Preserved anterior chordae tendineae is a possible risk factor for disturbing delivery of a transcatheter heart valve. Inserting a sheath just below the aortic valve for delivery of the transcatheter heart valve might be proposed as an alternative to avoid the chordae tendineae.

[Mediastinal Hematoma after Intravenous Thrombolytic Therapy for Cerebral Infarction in a Patient with a History of Total Aortic Arch Replacement].

An 80-year-old male patient with a history of total arch replacement for thoracic aortic aneurysm 5 years before was introduced to our hospital with a chief complaint of chest pain. Tissue plasminogen activator (t-PA) had been administrated because of acute brain infarction. A contrast-enhanced computed tomography (CT) scan demonstrated a large hematoma in the posterior mediastinum extending from the level of distal aortic arch to the descending aorta together with left pleural effusion. On the next day after admission, CT scan revealed that the hematoma became smaller. This is a rare case of a posterior mediastinal hematoma caused by t-PA with a history of total aortic arch replacement.

Valve-sparing partial root repair for aortic dissection limited to the right coronary sinus of Valsalva.

BACKGROUND AND AIM OF THE STUDY: To reveal a technical feasibility and safety of valve-sparing partial aortic root repair for spontaneous aortic dissection limited to the right coronary sinus of Valsalva. METHODS: A 68-year-old woman presented with chest pain. Twelve-lead electrocardiogram revealed atrioventricular dissociation and ST-segment elevation on II, III, and aVF. Enhanced computed tomography images showed aortic dissection limited to the right-coronary sinus and the other non-dilated sinuses of Valsalva. Localized aortic dissection was repaired by valve-sparing partial aortic root repair using a trimmed U-shaped Dacron graft and a felt strip, and the right coronary artery was revascularized by coronary artery bypass grafting using saphenous vein graft. RESULTS: The patient was discharged on postoperative day 12 with no complications. CONCLUSION: Valve-sparing partial aortic root repair with the patch and coronary artery bypass grafting for aortic dissection limited to the right coronary sinus of Valsalva were technically feasible and safe.