[Profuse Hemorage During Open Heart Surgery in a Patient Late After Liver Transplantation and Remission Stage Acquired Hemophilia].

A 72-year-old male presented with severe mitral regurgitation, moderate tricuspid regurgitation, and chronic atrial fibrillation. One month prior, he encountered difficulties with dialysis and was subsequently referred to our department for cardiac surgery. The patient's medical history includes living-donor liver transplantation for type C cirrhosis associated with acquired hemophilia A. The preoperative liver function was categorized as Child-Pugh grade B, with a model for end-stage liver disease( MELD) score of 23. His factor Ⅷ activity was close to the lower limit of the normal range. The patient underwent mitral valve replacement, tricuspid valve repair, and left atrial appendage closure. Initially, he experienced intractable bleeding, but hemostasis was easily achieved after administrating a factor Ⅷ preparation. Upon admission to the intensive care unit, his factor Ⅷ clotting activity was slightly below the normal range. Therefore, in cases where a patient with remission stage hemophilia A resulting in liver transplantation undergoes open heart surgery, it is crucial to have coagulation factor medication readily available, regardless of normal preoperative factor Ⅷ levels.

[Huge Tricuspid Pouch with Heart Failure:Report of a Case].

Tricuspid pouch forms during the spontaneous closure of a ventricular septal defect (VSD). Cases have been reported in which the tricuspid pouch was discovered for the first time during surgery and could not be distinguished from an aneurysm of the membranous septum( AMS). A 58-year-old woman had a heart murmur. Transthoracic echocardiography showed an aneurysm-like pouch protruding into the right ventricle. Magnetic resonance imaging could not distinguish between AMS and tricuspid pouch;however, contrast-enhanced computed tomography showed a VSD. The membranous structure comprised multiple lobules, and the tendon of the papillary muscles was continuous with the tricuspid valve. Intraoperatively, the tricuspid valve septal leaflet was adhered to the defect hole. It was incised along the annulus, the VSD was closed with a bovine pericardial patch, and the annulus of the tricuspid valve septal leaflet was suture closed. The patient was discharged after a good postoperative course.

Suppression of aortic expansion and contractile recovery in a rat abdominal aortic aneurysm model by biodegradable gelatin hydrogel sheet incorporating basic fibroblast growth factor.

Biodegradable gelatin hydrogel sheet (BGHS) incorporating basic fibroblast growth factor (bFGF) may inhibit the progression of abdominal aortic aneurysm (AAA). We investigated whether AAA in a rat model treated with BGHS soaked with bFGF can suppress aortic expansion and recover the contractile response of aneurysmal aortic wall. Experimental AAA was induced in 10-week-old male Sprague-Dawley rats with intra-aortic elastase infusion. Aortas of these rats were assigned to 4 groups (n = 6 each) as follows: Control group, aortas infused with saline; Elastase only group, aortas infused with elastase; Hydrogel group, aortas wrapped with saline-soaked BGHS after elastase infusion; and bFGF group, aortas wrapped with bFGF (100 µg)-soaked BGHS after elastase infusion. Preoperatively and on postoperative day (POD)7 and POD14, mean aortic maximal diameter was measured ultrasonographically. Aortic expansion ratio was calculated as: (post-infusion aortic diameter on POD14/pre-infusion aortic diameter × 100). Aortas were stained with Elastica van Gieson and α-smooth muscle actin to measure the ratio of elastic fibers and α-smooth muscle actin-positive cells area to the media area. Aortas on POD14 were cut into 2-mm rings and treated with contractile agent, then tension was recorded using myography. Maximum aorta diameters were significantly greater in Elastase only group, Hydrogel group, and bFGF group than in Control group (on POD14). Maximum diameter was significantly lower in bFGF group (3.52 ± 0.4 mm) than in Elastase only group (6.21 ± 1.4 mm on POD14, P < .05). On histological analysis, ratio of the area staining positively for elastic fibers was significantly greater in bFGF group (7.43 ± 1.8%) than in Elastase only group (3.76 ± 2.9%, P < .05). The ratio for α-smooth muscle actin-positive cells was significantly lower in Elastase only group (38.3 ± 5.1%) than in Control group (49.8 ± 6.7%, P < .05). No significant differences were seen between Elastase only group and bFGF group, but ratios tended to be increased in bFGF group. Consecutive mean contractile tensions were significantly higher in bFGF group than in Elastase only group. Maximum contractile tension was significantly higher in bFGF group (1.3 ± 0.4 mN) than in Elastase only group (0.4 ± 0.2 mN, P < .05). Aortic expansion can be suppressed and contractile responses of aneurysmal aortic wall recovered using BGHS incorporating bFGF.

Coronary Artery Bypass Grafting for an Anomalous Left Coronary Artery from the Pulmonary Artery in a 73-Year-Old Female.

Anomalous left coronary artery from the pulmonary artery (ALCAPA) in adults is a rare congenital coronary abnormality. We report a case of ALCAPA in a 73-year-old female managed by total arterial revascularization. doi: 10.1111/jocs.12755 (J Card Surg 2016;31:380-382).

Single coronary artery with bicuspid aortic valve stenosis and aneurysm of the ascending aorta: report of a case.

A 73-year-old man with a severely stenosed bicuspid valve and an aneurysm of the ascending aorta underwent valve and aortic surgery. Preoperative imaging revealed a single coronary artery arising from the right side of the sinus of Valsalva and a branch that perfused into the left side of the heart to pass through the front of the pulmonary artery. We replaced the aortic valve and ascending aorta, painstakingly avoiding damage to the coronary artery and obstruction of the sole coronary ostium.

Tumorectomy with right thoracotomy for synchronous left atrial myxomas from Carney complex: report of a case.

This report describes a case of synchronous left atrial myxomas from Carney complex resected through a right thoracotomy. The patient was a 30-year-old female that had previously been diagnosed with Carney complex following a genetic examination. Preoperative echocardiography showed a left atrial tumor, but intraoperative inspection revealed another tumor in the left atrium. Carney complex was first described in the 1980s and cardiac myxoma from Carney complex can occur in any cardiac chamber, presenting multiple times with postoperative recurrences, occurring at any age and without any predilection for gender, and is inherited in an autosomal-dominant manner. Treatment for cardiac myxoma from Carney complex is very important for patient mortality and morbidity and, despite the endocrine nature of the disorder, cardiologists and cardiac surgeons play an important role.

Mitral valve repair for Staphylococcus lugdunensis infective endocarditis: report of a case.

A 55-year-old male with an intermittent high-grade fever was diagnosed with infective endocarditis. He was indicated for surgery because periodic echocardiography revealed worsening mitral regurgitation and growing vegetation despite medication. An aneurysm of the P2 portion and all vegetations were removed via quadrangular resection of the P2 leaflet, and then the defect was repaired. An intraoperative assessment identified Staphylococcus lugdunensis as the causative bacterium. After postoperative antibiotic therapy for 5 weeks, the patient was discharged without either mitral regurgitation or signs of infection. Infective endocarditis caused by aggressive and destructive S. lugdunensis should be promptly and accurately treated via a surgical approach that prevents progressive tissue destruction and simplifies the surgical procedure for repair, rather than replacement.

Preoperative planning for endovascular aortic repair of abdominal aortic aneurysms: feasibility of nonenhanced MR angiography versus contrast-enhanced CT angiography.

PURPOSE: To compare vascular measurements to determine stent types and configurations for abdominal endovascular aneurysm repair (EVAR) by comparing results of contrast material-enhanced computed tomographic (CT) angiography and nonenhanced magnetic resonance (MR) angiography. MATERIALS AND METHODS: This prospective study was institutional review board approved, and all patients provided written informed consent. Fifty patients (45 men and five women; mean age, 76.0 years) admitted for elective abdominal EVAR underwent preoperative abdominal CT angiography (triplanar reformatted images; section thickness of 1-3 mm) and nonenhanced MR angiography (triplanar two-dimensional single-shot turbo field-echo images; section thickness of 6 mm). Two observers independently completed standard measurement and device selection forms for endovascular stent planning for CT and MR angiography. Pearson and intraclass correlation coefficients were calculated to evaluate intermodality and interobserver differences. RESULTS: No significant difference was found in aortic neck diameter (observer 1: CT, 18.5 mm; MR, 19.0 mm; P = .43) (observer 2: CT, 19.6 mm; MR, 19.3 mm; P = .59), aortic neck diameter 15 mm distal to the lowest renal artery (observer 1: CT, 19.2 mm; MR, 19.2 mm; P = .38) (observer 2: CT, 19.6 mm; MR, 19.6 mm; P = .91), aortic neck length (observer 1: CT, 43.6 mm; MR, 43.6 mm; P = .85) (observer 2: CT, 44.4 mm; MR, 44.0 mm; P = .93), or other key vascular measurements (P = .23-.99) for preoperative planning. These included aneurysm diameter, lowest renal artery to aortic bifurcation length, aortic bifurcation diameter, common iliac artery diameters, external iliac artery diameters, length between orifices of lower renal and internal iliac arteries, and iliac artery sealing length. CT and MR angiography measurements showed very strong correlation (r = 0.92-0.99). Intraclass correlation coefficients between observers ranged from 0.90 to 0.98. Stent types and configurations determined with CT measurements remained unaltered when reassessed with MR measurements. CONCLUSION: Measurements obtained with nonenhanced MR angiography appear equally accurate to those of CT angiography in the preoperative planning of abdominal EVAR.

Rheocarna® therapy after distal bypass surgery.

Objectives: Rheocarna® therapy has recently been reported to improve peripherally measured blood flow as an adjuvant treatment after revascularization in patients with chronic limb-threatening ischemia. We investigated whether skin perfusion pressure and continuous walking distance were improved by performing Rheocarna® therapy after distal bypass surgery. Methods: This study included 10 patients who underwent Rheocarna® therapy after distal bypass surgery between June 2022 and March 2023. Rheocarna® therapy was performed five times after distal bypass surgery, and the skin perfusion pressure and continuous walking distance after distal bypass surgery were compared with those after Rheocarna® therapy. Results: The average age was 74.7 years, and nine patients (90%) were male. All patients were undergoing dialysis, with an average of 14.5 years of dialysis history. There were six patients (60%) with diabetes mellitus and five (50%) with hyperlipidemia. The ankle-brachial index was 0.62 ± 0.36 before distal bypass surgery and 0.936 ± 0.16 after Rheocarna® therapy, indicating a significant increase (p = 0.0117). Skin perfusion pressure dorsalis pedis was 71.5 ± 27.0 mmHg after Rheocarna® therapy, showing a marked increase from the preoperative value (p = 0.0020). Skin perfusion pressure planta pedis was 65.0 ± 26.3 mmHg after Rheocarna® therapy, which was a significant increase from the preoperative value (p = 0.0293). The continuous walking distance was 78.5 ± 102.7 m after the Rheocarna® therapy, which was a significant increase from the preoperative value (p = 0.0039). Conclusion: The skin perfusion pressure and continuous walking distance were significantly improved by Rheocarna® therapy after distal bypass surgery.

Extra-Anatomical Bypass for Chronic Mesenteric Ischemia with Saphenous Vein Grafts from a Previous Axillofemoral Artery Bypass Graft: A Case Report.

A 74-year-old woman who was diagnosed with chronic mesenteric ischemia was under hemodialysis maintenance and had previously undergone axillobifemoral bypass surgery because of abdominal aortoiliac occlusion. Endovascular and antegrade or retrograde surgical revascularizations from the aortoiliac artery were contraindicated because of a severely calcified arteriosclerotic lesion, which included aortoiliac occlusion. During median laparotomy, revascularization consisting of bypass grafting from a previous prosthetic graft to the mesenteric arteries was performed using saphenous vein grafts. Although extra-anatomical bypass for chronic mesenteric ischemia is challenging, it provides a feasible option in cases where conventional endovascular or surgical revascularization is contraindicated.

Combined Prognostic Value of Preprocedural Protein-Energy Wasting and Inflammation Status for Amputation and/or Mortality after Lower-Extremity Revascularization in Hemodialysis Patients with Peripheral Arterial Disease.

Protein-energy wasting is associated with inflammation and advanced atherosclerosis in hemodialysis patients. We enrolled 800 patients who had undergone successful lower-extremity revascularization, and we investigated the association among the Geriatric Nutritional Risk Index (GNRI) as a surrogate marker of protein-energy wasting, C-reactive protein (CRP), and their joint roles in predicting amputation and mortality. They were divided into lower, middle, and upper tertiles (T1, T2, and T3) according to GNRI and CRP levels, respectively. Regarding the results, the amputation-free survival rates over 8 years were 47.0%, 56.9%, and 69.5% in T1, T2, and T3 of the GNRI and 65.8%, 58.7%, and 33.2% for T1, T2, and T3 of CRP, respectively (p < 0.0001 for both). A reduced GNRI [adjusted hazard ratio (aHR) 1.78, 95% confidence interval (CI) 1.24-2.59, p = 0.0016 for T1 vs. T3] and elevated CRP (aHR 1.86, 95% CI 1.30-2.70, p = 0.0007 for T3 vs. T1) independently predicted amputation and/or mortality. When the two variables were combined, the risk was 3.77-fold higher (95% CI 1.97-7.69, p < 0.0001) in patients who occupied both T1 of the GNRI and T3 of CRP than in those who occupied both T3 of the GNRI and T1 of CRP. In conclusion, patients with preprocedurally decreased GNRI and elevated CRP levels frequently experienced amputation and mortality, and a combination of these two variables could more accurately stratify the risk.

An unusual case of the right subclavian artery aneurysm resulting from long-term repetitive blunt chest trauma.

This case report describes a right subclavian artery aneurysm secondary to long-term repetitive blunt trauma. A 62-year-old man with a right subclavian artery aneurysm had had a history of bird hunting using a shotgun that impacted substantially against his right clavicula and shoulder weekly for >20 years. The patient underwent open repair with partial sternotomy and distal balloon control. The aneurysmal sac was resected, and the right subclavian artery was reconstructed with a primary end-to-end anastomosis. Histopathologic examination of the resected aneurysmal wall revealed that all three layers of the arterial wall were comparatively intact, with fibrosis and lipid deposition in the intima and in various degrees of degeneration in the media, suggesting a true aneurysm.

Case of persistent sciatic artery in a dialysis patient with critical limb ischemia.

Persistent sciatic artery is a rare congenital malformation (incidence rate, 0.03%-0.06%). We report the case of a 72-year-old male patient with persistent sciatic artery suffering from pain at rest and an ulcer on the left first toe. Angiography findings showed 90% stenosis in the distal persistent sciatic artery. Endovascular therapy was considered difficult because of a long stenotic lesion from the persistent sciatic artery to the popliteal artery and extremely high calcification of the whole body. Because of poor blood flow to the lower leg, vascular prosthesis would have increased the risk of thrombotic occlusion. Therefore, below-knee femoropopliteal bypass using the great saphenous vein graft was performed, which led to the healing of the ulcer on the left first toe. Contrast-enhanced computed tomography of the lower limbs was performed to confirm that the bypass blood flow was good. The patient was discharged on postoperative day 5.

Rare epithelioid hemangioendothelioma in the brachiocephalic vein for long-term survival after surgery: A case report.

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor. In this report, we describe the case of a 62-year-old man who presented with pain in the left clavicle and swelling of the left upper limb. Contrast-enhanced computed tomography revealed an intravascular tumor, which was completely resected surgically. Histopathological examination and immunohistochemical staining revealed that it was epithelioid hemangioendothelioma with occurrence in the left brachiocephalic vein. It has been 6 years since the surgery was performed, and no recurrence has been observed. Epithelioid hemangioendothelioma may recur or metastasize and therefore requires careful follow-up.

Thoracic endovascular aortic repair for chronic aortic dissection after total arch replacement for aberrant right subclavian artery: A case report.

An aberrant right subclavian artery (ARSA) is an extremely rare congenital anomaly that forms during aortic arch development. Most reports of thoracic endovascular aortic repair (TEVAR) described an ARSA in the right aortic arch, but it is rare in the left aortic arch. We present the case of a 66-year-old man who underwent total arch replacement because of acute type A aortic dissection. An outpatient follow-up examination revealed that the aortic diameter enlargement exceeded 60 mm because of false lumen entry from the ARSA. Therefore, surgical intervention was planned. TEVAR, ARSA embolization, and bilateral axillary bypass surgery were successfully performed for a chronic dissecting aortic aneurysm for which the ARSA was the inflow route. He was discharged 12 days after surgery. Four years later, no enlargement of the aneurysm diameter was observed. TEVAR is a minimally invasive and useful treatment option for chronic type B dissections with an ARSA associated with the left aortic arch; however, patients with an ARSA have fragile blood vessels and require careful follow-up.

Impact of Hemodialysis on Clinical Outcomes in Patients Undergoing Lower Extremity Bypass Surgery for Peripheral Artery Disease-10-year Follow-Up Study.

We investigated the clinical impact of hemodialysis on long-term outcomes of bypass surgery in patients with peripheral artery disease. We evaluated 660 consecutive patients who underwent successful bypass surgery (392 hemodialysis and 268 non-hemodialysis). The endpoint was amputation-free survival (AFS). To minimize differences in clinical characteristics between the 2 groups, propensity score matching was performed. The AFS rates for 10-year follow-up were 39.3% and 67.7% in hemodialysis and non-hemodialysis patients [hazard ratio (HR) 2.21, 95% confidence interval (CI) 1.65-3.01, P < .0001]. Cumulative incidence of amputation was higher in the hemodialysis group than in the non-hemodialysis group [(19.4 vs 8.4%, HR 2.15, 95% CI 1.29-3.74, P = .0027). In a matched cohort (n = 210 each), AFS was still lower in the hemodialysis patients (53.1 vs 66.3%, HR 1.94, 95% CI 1.36-2.82, P = .0003). However, there was no significant difference in amputation rate between the groups (10.5 vs 10.6%, HR .97, 95% CI 0.49-1.87, P = .93). In a sub-analysis of patients with critical limb ischemia, similar results were obtained. The 10-year AFS was consistently lower in the hemodialysis group than in the non-hemodialysis group. However, the amputation rate was comparable between the groups when matched for the differences in clinical characteristics.

Utility of Noncontrast Magnetic Resonance Angiography for Aneurysm Follow-Up and Detection of Endoleaks after Endovascular Aortic Repair.

OBJECTIVE: To assess the noncontrast two-dimensional single-shot balanced turbo-field-echo magnetic resonance angiography (b-TFE MRA) features of the abdominal aortic aneurysm (AAA) status following endovascular aneurysm repair (EVAR) and evaluate to detect endoleaks (ELs). MATERIALS AND METHODS: We examined four aortic stent-grafts in a phantom study to assess the degree of metallic artifacts. We enrolled 46 EVAR-treated patients with AAA and/or common iliac artery aneurysm who underwent both computed tomography angiography (CTA) and b-TFE MRA after EVAR. Vascular measurements on CTA and b-TFE MRA were compared, and signal intensity ratios (SIRs) of the aneurysmal sac were correlated with the size changes in the AAA after EVAR (AAA prognoses). Furthermore, we examined six feasible b-TFE MRA features for the assessment of ELs. RESULTS: There were robust intermodality (r = 0.92-0.99) correlations and interobserver (intraclass correlation coefficient = 0.97-0.99) agreement. No significant differences were noted between SIRs and aneurysm prognoses. Moreover, "mottled high-intensity" and "creeping high-intensity with the low-band rim" were recognized as significant imaging findings suspicious for the presence of ELs (p < 0.001), whereas "no signal black spot" and "layered high-intensity area" were determined as significant for the absence of ELs (p < 0.03). Based on the two positive features, sensitivity, specificity, and accuracy for the detection of ELs were 77.3%, 91.7%, and 84.8%, respectively. Furthermore, the k values (0.40-0.88) displayed moderate-to-almost perfect agreement. CONCLUSION: Noncontrast MRA could be a promising imaging modality for ascertaining patient follow-up after EVAR.

Suppression of right ventricular hypertrophy after extensive pulmonary resection in rats by granulocyte colony-stimulating factor.

BACKGROUND: The objective of the present study was to investigate the effects of granulocyte colony-stimulating factor (G-CSF) on right ventricular hypertrophy following extensive pulmonary resection in rats. MATERIALS AND METHODS: Adult rats were divided into four groups: (1) Group S (right thoracotomy only); (2) Group L (right three lobectomy); (3) Group LG10 (Group L+G-CSF [10microg/kg/d]); and (4) Group LG100 (Group L+G-CSF [100microg/kg/d]). At postoperative day 21, weight ratio of the right ventricular to the left ventricle plus septum (RV/LV+S, indicator of right ventricular hypertrophy) were measured, and a histopathological study was conducted to determine percentage wall thickness of peripheral pulmonary arteries and proliferating cell nuclear antigen labeling index (indicator of oxidative DNA damage) of right ventricles. RESULTS: Mean RV/LV+S for Group S was 0.27+/-0.02, significantly smaller than that for the lobectomy groups (Group L, LG10, LG100; 0.47+/-0.05, 0.35+/-0.02, 0.38+/-0.05). G-CSF significantly suppressed right ventricular hypertrophy. Mean medial wall thickness of peripheral pulmonary arteries for Group S was 13.6% +/- 4.9%, significantly smaller than that for Group L (22.9% +/- 9.6%). Compared with Group L, G-CSF reduced medial wall thickness (LG10, 17.6% +/- 9.5%; LG100, 18.0% +/- 11.2%). Incidence of proliferating cell nuclear antigen positive nuclei for Group S was 1.07% +/- 0.49%, significantly smaller than that for Group L (13.77% +/- 5.87%). G-CSF significantly reduced the incidence of proliferating cell nuclear antigen positive nuclei (LG10, 4.04% +/- 2.14%; LG100, 3.18% +/- 1.66%). CONCLUSIONS: G-CSF administration not only reduce medial wall thickness of peripheral pulmonary arteries but also directly protect cardiomyocytes of the right ventricle, thus suppressing right ventricular hypertrophy. These results suggest that low-dose G-CSF administration can prevent right heart failure following extensive pulmonary resection.

Neovascularization in pericarditis: a possible etiology of hemopericardium.

Hemorrhagic pericardial effusion is life-threatening and mostly occurs during pericarditis; however, its underlying mechanism is unclear. We report a case of pericardial hematoma with obvious hemorrhage. A 56-year-old man without prior chest trauma presenting with exertional dyspnea and abdominal fullness was treated for idiopathic pericarditis. The echocardiogram showed a thickened pericardium with effusion. Imaging showed extravasation and neovascularization. Following ineffective pharmacotherapy, we performed pericardiectomy. The site of bleeding was undetectable. Because parietal pericardiectomy with hematoma evacuation did not improve diastolic function, we removed the epicardium. During the follow-up period, the patient remained almost asymptomatic. We identified neovascularization as the potential source of idiopathic pericardial hemorrhage.