[Giant Aneurysm of Sinus of Valsalva;Report of a Case].

Aneurysm of the sinus of Valsalva is a relatively rare disease. The patient was a 59-year-old female with a complaint of dyspnea. A very large extra-cardiac type aneurysm of sinus of Valsalva, 75 mm in diameter, was detected, and modified-Bentall operation (J-graft Valsalva 26 mm:Carpentier-Edwards Magna Ease 23 mm) was performed. The patient recovered uneventfully after the operation and was discharged on the 17th postoperative day.

Surgical Repair of Cervical Aortic Arch With Brain Circulation Anomaly Through Clamshell Incision.

We report the successful surgical repair of a cervical aortic arch and diverticulum with a brain circulation anomaly through a clamshell incision. Because of the reliability of selective antegrade cerebral perfusion and superior exposure, we chose an approach through a clamshell incision. We describe the utility of this approach for treating a cervical aortic arch with a diverticulum.

Early and midterm results of transapical and right axillary artery cannulation for acute aortic dissection.

BACKGROUND: We combined transapical cannulation and right axillary artery cannulation in the repair of acute type A aortic dissection in order to reduce mortality and morbidity in the presence of risk of malperfusion. Early and midterm outcomes were evaluated. METHODS: Between October 2009 and March 2012, 23 aortic dissection patients (age, 54.3 ± 13.5 years) received graft replacement using a combination of transapical and right axillary artery cannulation. Preoperative malperfusion was present in 16 patients (69.6%). Cardiopulmonary bypass was initiated with axillary artery cannulation applied via the right axilla and right atrial drainage, then aotric cannulation applied via the left ventricular apex. We retrospectively investigated mortality and morbidity as well as cardiac function, which were evaluated echocardiographically during hospitalization and once a year postoperatively. RESULTS: All patients received total arch replacement. In-hospital mortality was 4.3%, and no patient developed intraoperative malperfusion. Intraoperative stroke occurred in one patient (4.3%), and three patients (13.0%) suffered from delayed stroke (10-24 days). These delayed strokes might have resulted from cardiogenic thrombus, although no intracardiac thrombus was found. Mean ejection fraction was 66.1 ± 10.9% in the early postoperative period and 73.1 ± 8.7% midterm. There was no left ventricular asynergy or intracardiac thrombus seen on either early or midterm echocardiography. CONCLUSION: Transapical cannulation with right axillary artery cannulation is a safe and effective procedure that can reduce operative risk associated with aortic dissection. Although transapical cannulation does not appear to impair cardiac function, it may confer a risk of delayed stroke.

[Left atrium thrombus after mitral valve replacement presented with syncope; report of a case].

Left atrial free ball thrombus (LABT) after mitral valve replacement (MVR) is very rare, and sudden death may occur by thrombus impaction to the mitral valve orifice. A 81-year-old woman who underwent MVR and tricuspid annuloplasty ten years ago presented with syncope. She was admitted to a hospital, and echocardiography revealed a LABT. When she took sitting position, she fainted. The free ball thrombus possibly impacted mitral valve orifice. She was transferred to our hospital and an emergent operation was performed. There was a LABT of 4 cm in diameter, which was removed. Postoperative course was uneventful. There are 12case reports which described LABT after MVR, and anticoagulant therapy was insufficient in most of those cases. Strict anticoagulant therapy is important to prevent left atrial thrombus after MVR.

Pericoronary pseudotumor caused by helicobacter cinaedi.

Cardiac tumors and tumor-like lesions are uncommon; most are true neoplasms. We here report a case of a pericoronary tumor-like lesion surrounding the right coronary artery in a 39-year-old man who presented with fever and chest pain. Although clarithromycin was administered for 1 week, his fever persisted. Helicobacter cinaedi (H. cinaedi) was isolated from blood cultures and found to be sensitive to ceftriaxone. A computed tomography scan showed a tumor-like lesion with no (18)F-fl uorodeoxyglucose uptake surrounding the right coronary artery. After administration of ceftriaxone, the tumor-like lesion diminished in size according to meticulous computed tomography examinations. We therefore concluded that it was caused by H. cinaedi infection. The patient has been followed up closely for 1 year and remains asymptomatic.

Delayed esophageal perforation secondary to thoracic aortic aneurysm rupture in a patient with human immunodeficiency virus infection.

A 65-year-old man infected with human immunodeficiency virus underwent emergency surgery for rupture of a mycotic descending thoracic aneurysm. The aneurysm was replaced with a prosthetic graft wrapped with omentum. Esophageal perforation occurred 3 weeks after surgery. The patient's condition remained stable, and we adopted a conservative treatment. The esophageal fistula had not healed completely and a biopsy of the scar revealed gastric cancer. We performed a distal gastrectomy, Roux-Y reconstruction, and enterostomy for enteral feeding. Follow-up endoscopy revealed healing of the fistula, and the patient was eventually discharged. We managed this potentially fatal complication with minimally invasive treatment.

Tracheo-Bronchial Obstruction and Esophageal Perforation after TEVAR for Thoracic Aortic Rupture.

A 67-year-old man was referred to our hospital for an ascending aortic aneurysm, thoracoabdominal aortic aneurysm and aortic regurgitation. Graft repair of the thoracic aortic arch and aortic valve replacement was given priority and completed, however he developed descending aortic rupture before the second scheduled surgery, and endovascular stent grafting was performed. He subsequently developed tracheobronchial obstruction and esophageal perforation. The patient underwent urgent esophagectomy and enterostomy with continuity later reestablished. However, he died of sepsis 5 months after surgery. Despite the less invasive nature of endovascular treatment, esophageal perforation can nevertheless occur and postoperative vigilance is well warranted.

Prosthetic valve endocarditis after double valve replacement with the Manouguian procedure.

Prosthetic valve endocarditis is a rare but severe complication after double mitral and aortic valve replacement. It is debated whether or not all prostheses should be replaced simultaneously, because of high operative mortality with redo double valve replacement. We report a case of prosthetic valve endocarditis after double mitral and aortic valve replacement with the Manouguian procedure. A 56-year-old man had undergone double valve replacement 12 years prior and presented with high fever 2 months after dental treatment. Enterococcus faecalis was isolated from blood cultures twice. Transthoracic echocardiography showed perivalvular mitral regurgitation, but no vegetations or abscess. Transesophageal echocardiography revealed an abscess on the aortomitral continuity of the Manouguian patch. We removed all previous prostheses and performed redo aortic and mitral valve replacements with a repeat Manouguian procedure. The postoperative course was satisfactory. Precise preoperative evaluation by transesophageal echocardiography and radical removal of the infected prostheses resulted in successful treatment.

Prosthetic valve endocarditis caused by Staphylococcus capitis: report of 4 cases.

Although Staphylococcus capitis is considered to be a rare causative organism for prosthetic valve endocarditis, we report 4 such cases that were encountered at our hospital over the past 2 years. Case 1 was a 79-year-old woman who underwent aortic valve replacement with a bioprosthetic valve and presented with fever 24 days later. Transesophageal echocardiography revealed an annular abscess in the aorto-mitral continuity and mild perivalvular regurgitation. We performed emergency surgery 5 days after the diagnosis of prosthetic valve endocarditis was made. Case 2 was a 79-year-old woman presenting with fever 40 days after aortic valve replacement with a bioprosthesis. Transesophageal echocardiography showed vegetation on the valve, and she underwent urgent surgery 2 days after prosthetic valve endocarditis was diagnosed. In case 3, a 76-year-old man presented with fever 53 days after aortic valve replacement with a bioprosthesis. Vegetation on the prosthetic leaflet could be seen by transesophageal echocardiography. He underwent emergency surgery 2 days after the diagnosis of prosthetic valve endocarditis was made. Case 4 was a 68-year-old woman who collapsed at her home 106 days after aortic and mitral valve replacement with bioprosthetic valves. Percutaneous cardiopulmonary support was started immediately after massive mitral regurgitation due to prosthetic valve detachment was revealed by transesophageal echocardiography. She was transferred to our hospital by helicopter and received surgery immediately on arrival. In all cases, we re-implanted another bioprosthesis after removal of the infected valve and annular debridement. All patients recovered without severe complications after 2 months of antibiotic treatment, and none experienced re-infection during 163 to 630 days of observation. Since the time interval between diagnosis of prosthetic valve endocarditis and valve re-replacement ranged from 0 to 5 days, early surgical removal of the infected prosthesis and an appropriate course of antibiotics were attributed to good clinical outcomes in our cases.

Indicators of survival after open repair of ruptured abdominal aortic aneurysms and an index for predicting aneurysmal rupture potential.

BACKGROUND: The aims of this study were to assess variables associated with survival in patients undergoing ruptured abdominal aortic aneurysm (RAAA) repair and to develop an index other than the aneurysmal diameter to predict rupture potential. METHODS: This study included 43 consecutive patients who underwent open surgery for RAAAs. RESULTS: The mortality rate was 18.6% (8/43). The ratio between the maximum aneurysmal diameter and the length (along the central axis) from the aneurysmal neck to the point at which the diameter was three-fourth of the maximum aneurysmal diameter was used as an index to predict aneurysmal rupture potential. The index score was 2.7 ± 1.2 in the RAAA and 1.9 ± 0.9 in the EAAA (p = 0.018). For aneurysms of ≤ 6-cm diameter, the index score was 3.0 ± 1.0 in the RAAA and 1.8 ± 0.9 in the EAAA (p = 0.03). All patients in the EAAA except one had an index score of < 2.3 and 6 of the 7 patients with RAAA had a score of > 3. CONCLUSIONS: The results suggest that patients with AAA having scores of > 3 are at high risk of rupture. This index would be useful for decision making regarding repair of AAA, especially in the borderline cases.

[The number of cardiovascular surgeons is decreasing in Nagano].

Shortage of medical doctors has been conspicuous since the residency program has been changed in 2004. We investigated the changes in the number of cardiovascular surgeons, surgical cases and institutes of Nagano from 1996 to 2008. The number of cardiovascular surgeons decreased from 28 to 19. The number of newly joined cardiovascular surgeons were 2.7 +/- 1.4/year from 1996 to 2001 and 1.1 +/- 0.4/year from 2002 to 2008. The number of retirement were 0.7 +/- 0.8/year and 2.3 +/- 1.0/year from 1996 to 2001 and from 2002 to 2008, respectively. The number of surgery cases increased from 340 in 1996 to 771 in 2008. Kaplan-Mayer analysis showed the 50% of cardiovascular surgeons retired in 19 years of their career, and the only 20% of surgeons survived after 29 years. The number of newly joined general surgeons was the only 3 since 2004. We are consolidating the institutes of cardiovascular surgery in Nagano to perform more surgery by fewer surgeons. It is important that working condition of cardiovascular surgeon adapt to young doctor's favor, and new positions should be created for elder cardiovascular surgeons to prevent early retirement.

Bone marrow cell-seeded biodegradable polymeric scaffold enhances angiogenesis and improves function of the infarcted heart.

BACKGROUND: The present study examined whether a bioengineered polyglycolic acid cloth (PGAC) impregnated with bone marrow cells (BMC) improved the function and angiogenesis of the infarcted heart. METHODS AND RESULTS: The coronary artery was ligated in Lewis rats and the infarcted area was covered with a PGAC in group 1 (n=8), with a PGAC containing basic-fibroblast growth factor (b-FGF) in group 2 (n=11) and a PGAC containing b-FGF and freshly isolated BMC in group 3 (n=10). In addition, BMC derived from transgenic mice expressing green fluorescent protein (GFP)-BMC were seeded into a PGAC, which was sutured over the infarcted area of C57BL/6 mice (n=5). In the rat study, developed and systolic pressures, dp/dt max and dp/dt min) were the highest in group 3, as were the capillary density in the PGAC and infarcted area. In the mouse study, there were few GFP-BMC in the PGAC, but none in the infarcted area. CONCLUSIONS: A PGAC with BMC improved cardiac function by inducing angiogenesis without migration of BMC. Freshly isolated BMC work as angiogenic inducers and a PGAC is useful as a "drug delivery system".

Stimulation of P19CL6 with multiple reagents induces pulsating particles in vivo.

OBJECTIVE: Injection of stem cells into ischaemic areas of the heart is expected to be an effective method for myocardial regeneration. The embryogenic carcinoma (EC) cell line P19CL6 is known to differentiate into cardiomyocytes when cultured with dimethyl sulfoxide (DMSO) and is expected to be a promising source for regenerative therapy in cardiac disease. To establish a high-yield method of cardiomyocyte differentiation, P19CL6 cells were double-stimulated with 5-azacytidine. Double stimulation-induced cardiomyocytes were also transplanted into ectopic sites in mice and their function evaluated. METHODS AND RESULTS: To induce differentiation under adherent conditions, P19CL6 cells were incubated in growth medium with 10 microM 5-azacytidine for 24 h. After 5-azacytidine treatment, P19CL6 cells were incubated with 1% DMSO for nine days until they began to pulsate. Prior to transplantation, cells were treated again with 5-azacytidine. Differentiated cells were injected into the greater omentum, para-aorta region of the retroperitoneum and peri-femoral artery of adult BALB/c nude mice. Nine days after transplantation, irregularly pulsating tissues at a rate slower than the host heart were observed in the transplanted sites. Light microscopy showed formation of cardiac muscle tissues originating from P19CL6 cells. Differentiated cardiomyocytes were positive for cardiac troponin I, cadherin and alpha-smooth muscle actin, and the expressions of Csx/Nkx2.5 and GATA4 mRNAs were up-regulated. Electron microscopy demonstrated components specific to cardiomyocytes, such as Z-bands, desmosomes, fasciae adherens, myofibrils and mitochondria, which confirmed successful heterotopic cardiac muscle differentiation from P19CL6 cells. CONCLUSION: This study demonstrated high-yield cardiac muscle differentiation of P19CL6 by 5-azacytidine and DMSO double stimulation and successful formation of cardiac muscle-like tissue by ectopic transplantation of cardiomyocytes derived from P19CL6 into the retroperitoneal area as well as into the peripheral vessel area.

Acute effects of direct cell implantation into the heart: a pressure-volume study to analyze cardiac function.

BACKGROUND: To safely implant cells into the myocardium, we must establish a volume that prevents compromising cardiac performance. We studied pressure-volume (PV) to investigate the adverse effects of direct cell implantation in the acute phase. METHODS: We used 21 minipigs. In the normal heart model, we studied PV by measuring various parameters (including end-systolic pressure, end-systolic elastance, dp/dtmax, end-diastolic volume, and time constant of isovolumetric left ventricular pressure fall [Tau]). We injected solutions into the left ventricular free wall (15 cm(2)). Sampling points were at baseline and after injection of saline (Group I, n = 4) or of blood (Group II, n = 4) at volumes of 1 ml and 10 ml up to 30 minutes after injection. In Group II, we injected additional blood (10 ml) 4 times. In the ischemic heart model, 1 month after ligating the left anterior descending artery, we injected 1 ml saline (Group III, n = 4), bone marrow mononuclear cells (10(8) cells/1 ml; Group IV, n = 4), or bone marrow stromal cells (10(8) cells/1 ml; Group V, n = 3). We studied PV before and after injection. RESULTS: In Group I, we found no significant changes in parameters. In Group II, end-diastolic volume after 10-ml injection (24.4 +/- 3.6 ml) was smaller than end-diastolic volume at baseline (29.5 +/- 5.8 ml, p < 0.01). Tau after 10-ml injection (39.4 +/- 5.3 msec) was greater than at baseline (35.6 +/- 4.0 msec, p < 0.01). One pig died of ventricular fibrillation after a 20-ml injection of blood. We observed no detrimental effects in Groups III, IV, and V. CONCLUSIONS: More than 10 ml cell suspension compromised diastolic function. We safely performed direct injection of bone marrow cells (1 x 10(8)/1 ml).

Bone marrow is a source of regenerated cardiomyocytes in doxorubicin-induced cardiomyopathy and granulocyte colony-stimulating factor enhances migration of bone marrow cells and attenuates cardiotoxicity of doxorubicin under electron microscopy.

BACKGROUND: It has been reported previously that granulocyte colony-stimulating factor (GCSF) injection improves infarcted heart function, but the mechanism remains unclear. In this study we sought to determine whether GCSF-mobilized bone marrow cells could regenerate neo-myocardium and repair doxorubicin-induced cardiomyopathy. METHODS: C57BL/6 mice were irradiated and bone marrow cells (BMC; 1 x 10(6)) from green fluorescent protein (GFP) mice (GFP-BMC) were transplanted intravenously, followed by splenectomy. Doxorubicin (2.5 mg/kg, 6 times for 2 weeks) was administered intraperitoneally 2 weeks later. GCSF (50 microg/kg/day for 8 days) was administered sub-cutaneously after doxorubicin injection (Group I, n = 11) and 3 weeks later (Group II, n = 8), and saline was injected in Group III animals (n = 8). Eight weeks after doxorubicin injection, the excised hearts were studied immunologically and electron microscopically. RESULTS: Survival rates were 81.8% in Group I, 50.0% in Group II and 62.5% in Group III. The number of GFP-BMC in Group I (15.4 +/- 7.4 per high-power field) was highest (p < 0.05). In all groups, cardiac troponin I-positive cells derived from GFP-BMC were observed in the hearts. GFP-BMC in hearts stained positively against cardiac troponin I (4.3 +/- 2.5%), myosin heavy chain (5.0 +/- 4.3%), atrial natriuretic peptide (ANP; 3.9 +/- 2.4%) and connexin 43 (11.9 +/- 7.3%) in Group I. Myofibrils, mitochondria and fundamental architecture were almost all preserved in Group I, whereas hearts were severely damaged in Groups II and III. CONCLUSIONS: Bone marrow was shown to be one of the sources of regenerated cardiomyocytes in the doxorubicin-induced cardiomyopathic heart. Early administration of GCSF enhanced the migration of bone marrow cells into the heart, and attenuated the cardiotoxicity of doxorubicin.

Bone marrow mononuclear cell transplantation had beneficial effects on doxorubicin-induced cardiomyopathy.

BACKGROUND: Cell transplantation is a promising therapy for treating end-stage heart failure. Bone marrow mononuclear cells (BMMNC) have been used to enhance angiogenesis in ischemic heart disease. However, the effect of BMMNC transplantation in non-ischemic dilated cardiomyopathy is unknown. In this study, we evaluated the efficacy of BMMNC transplantation in doxorubicin-induced cardiomyopathy in a rat model. METHODS: Doxorubicin (15 mg/kg, IP) was introduced into 52 Lewis rats. They were divided into 3 groups at 4 weeks after injection: transplant group (TX, BMMNC [1 x 10(6)] implantation, n = 18), control group (CN, saline injection, n = 18), and sham group (SH, thoracotomy, n = 16). At 4 weeks after surgery, we used echocardiography to measure systolic left ventricular diameter (LVDs), diastolic left ventricular diameter (LVDd), fractional shortening (FS), and left ventricular wall thickness/LVDs. We used a Langendorff apparatus to measure systolic, diastolic, and developed pressures. We used radioimmunoassay to measure circulating atrial natriuretic peptide concentration, and we performed histologic study, including electron-microscopic study. RESULTS: Left ventricular wall thickness/LVDs in the TX group was the largest of all groups (p < 0.05). Systolic and developed pressures in the TX group were the greatest (p < 0.005). Systolic left ventricular diameter, FS, and end-diastolic pressure in the TX group were smaller than in the SH group (p < 0.05). These cardiac parameters did not differ significantly between TX and CN groups, but secondary changes (decreased heart weight, developed ascites, and increased atrial natriuretic peptide concentration) caused by doxorubicin-induced heart failure were most attenuated in the TX group. In the TX group, vascular density was greatest (p < 0.05) in the left ventricular free wall and in the septum. In addition, electron microscopy showed that myocardium in the TX group was most maintained. CONCLUSION: Bone marrow mononuclear cell transplantation had beneficial effects in doxorubicin-induced cardiomyopathy.

A novel application of myocardial contrast echocardiography to evaluate angiogenesis by autologous bone marrow cell transplantation in chronic ischemic pig model.

OBJECTIVES: We investigated the feasibility of myocardial contrast echocardiography (MCE) to evaluate regional perfusion after bone marrow cell transplantation. BACKGROUND: The myocardial microvessels improved by cell transplantation are too small to visualize with conventional angiography. METHODS: Fourteen mini-pigs from the Nippon Institute for Biological Science were used. The proximal left anterior descending coronary artery was ligated. One month later, nine pigs survived. Six pigs received autologous cell transplantation into the left ventricular anterior wall: bone marrow mononuclear cells (BMMNCs) (n = 3) and bone marrow stromal cells (BMSCs) (n = 3). The other three pigs received saline (control group, n = 3). The pigs were sacrificed one month later. Myocardial contrast intensity (MCI) with a contrast agent was measured using the SONOS 5500 system (Philips). Capillary density (CD) and MCI were measured at four areas: anteroseptum (nontransplanted infarct area), anterior wall (transplanted infarct area), septum (border zone), and lateral wall (normal). We compared the anteroseptum with the anterior wall by MCI and CD. RESULTS: In the BMMNC and BMSC subsets, the CD of the anterior wall was higher than that of the anteroseptum (p < 0.001). There was a linear relation between MCI and CD (acoustic unit [AU2] = 0.234 CD + 0.010, r = 0.92, p < 0.001). At one month after cell transplantation, MCI of the anterior wall increased in the BMMNC and BMSC subsets (p < 0.05), although it did not change in the control group. The ratio of wall thickness (systole/diastole) in the transplanted infarct area was larger than that in the nontransplanted infarct area (p < 0.01). CONCLUSIONS: Myocardial contrast echocardiography is useful to evaluate regional perfusion, which was enhanced by bone marrow cell transplantation.

G-CSF promotes bone marrow cells to migrate into infarcted mice heart, and differentiate into cardiomyocytes.

A recent study showed that granulocyte-colony stimulating factor (G-CSF) treatment improved the infarcted cardiac function. Although mobilized stem cells may affect it, the mechanism is unclear. In this study, we investigated the origins of stem cells and phenotypic changes of the migrated cells, and evaluated the efficacy of G-CSF. Eighteen C57BL/6 mice were irradiated (900 cGy) and GFP mouse-derived bone marrow cells (GFP-BMC: 10(6) cells) were injected via a tail vein followed by splenectomy 4 weeks later. Ligation of the left descending coronary artery was performed 2 weeks later. Recombinant human G-CSF (200 microg/kg/day) was injected for 3 days before and 5 days after ligation (group 1, n = 10). Saline was injected in group 2 (n = 8). Four weeks after infarction, hearts and other organs were fixed for histology. The survival rate after postoperative day 3 in group 1 was 100%, while that in group 2 was 50% (p = 0.03). Bone marrow-derived GFP cells (BMD-GFP) in group 1 (103.3+/-71.9/mm2) were located at the infarcted border area significantly more than those in group 2 (43.6+/-23.7/mm2) (p < 0.0001). BMD-GFP cells were positive for troponin I (16.6%), myosin heavy chain-slow (16.7%), and nestin (8.8%) in group 1. Ki-67-positive BMD-GFP in group 1 (10.0+/-7.0/mm2) were significantly more than those in group 2 (4.8+/-6.1/mm2) (p = 0.01). G-CSF increased the survival rate after infarction. G-CSF promoted BMC to migrate into the infarcted border area. Bone marrow was one of the origins of regenerated cardiomyocytes.