Aortic Arch Enlargement and Coarctation Repair of Preserving the Lesser Curvature of the Aortic Arch Through a Left Thoracotomy in Neonates.

The aim of this study was to analyze the aortic arch repair technique for preserving the lesser curvature without cardiopulmonary bypass through a left thoracotomy in neonates with coarctation of the aorta (CoA) and a hypoplastic distal aortic arch (HDAA). HDAA was defined as z-score of the aortic arch < - 2.5. Twenty-four neonates with CoA and HDAA were retrospectively studied. Patients underwent enlargement of the HDAA associated with CoA repair when their z-scores were < - 4. They were divided into 2 groups on the basis of the preoperative z-score of the distal aortic arch: group 1 (n = 14), z-score ≥ - 4; group 2 (n = 10), z-score < - 4. Twenty-two patients had intracardiac defects. Follow-up ranged from 0.9 to 20.1 years (median 11.6 years). The z-scores of the distal aortic arch were significantly smaller in group 2 than group 1 (- 5.09 ± 1.05 vs - 3.19 ± 0.36, p < 0.001). There were no hospital deaths and no hypertension. All dimensions of the aortic arch in both groups revealed significant catch-up growth (p < 0.02). All patients showed a pressure gradient ≤ 5 mmHg across the aortic arch and between the arms and legs at the latest follow-up. Two patients showed an angulated arch deformity over 10 years later. This technique provided good catch-up growth and a low incidence of reobstruction and deformity of reconstructed aortic arch in both groups. These results suggest that this modification might be considered as one choice of technique for CoA and HDAA.

Prognostic Risk Analyses for Postcardiotomy Extracorporeal Membrane Oxygenation in Children: A Review of Early and Intermediate Outcomes.

We evaluated the morbidity and mortality of children requiring postcardiotomy extracorporeal membrane oxygenation (ECMO) to determine independent factors affecting early and intermediate outcomes. Between January 2002 and December 2015, 79 instances of ECMO after cardiac surgery in 73 children were retrospectively reviewed. Follow-up was completed in December 2016. Predictive risk analyses were employed concerning weaning of ECMO, hospital discharge, and mortality after discharge. Age and weight were 14.9 ± 25.6 months and 7.0 ± 5.3 kg, respectively. Median support time was 8.3 ± 4.4 days. Sixty-seven (85%) were successfully weaned off ECMO and 48 (61%) survived to hospital discharge. Multi-variate logistic regression analysis identified the first day to obtain negative fluid balance after initiation of support (adjusted odds ratio = 0.42), high serum lactate levels (0.97), and high total bilirubin (0.84) during support as significant independent factors associated with successful separation from ECMO. The first day of negative fluid balance (0.65) after successful decannulation was an independent risk factor for survival to hospital discharge. After hospital discharge, actuarial 1-year, 5-year, and 10-year survival rates were 94%, 78%, and 78%, respectively. Low weight increased the risk of death after hospital discharge by a multi-variate Cox hazard model. High serum lactate, high serum bilirubin, and unable to obtain early negative fluid balance during support impacted mortality of decannulation. Obtaining a late negative fluid balance in post-ECMO were independent risk factors for death after successful weaning. Low weight affected intermediate outcomes.

Effectiveness of cardiac surgery in patients with trisomy 18: a single-institutional experience.

BACKGROUND: Surgical repair for cardiac lesions has rarely been offered to patients with trisomy 18 because of their very short lifespans. We investigated the effectiveness of cardiac surgery in patients with trisomy 18. Patients and methods We performed a retrospective analysis of 20 consecutive patients with trisomy 18 and congenital cardiac anomalies who were evaluated between August, 2003 and July, 2013. All patients developed respiratory or cardiac failure due to excessive pulmonary blood flow. Patients were divided into two subgroups: one treated surgically (surgical group, n=10) and one treated without surgery (conservative group, n=10), primarily to compare the duration of survival between the groups. RESULTS: All the patients in the surgical group underwent cardiac surgery with pulmonary artery banding, including patent ductus arteriosus ligation in nine patients and coarctation repair in one. The duration of survival was significantly longer in the surgical group than in the conservative group (495.4±512.6 versus 93.1±76.2 days, respectively; p=0.03). A Cox proportional hazard model found cardiac surgery to be a significant predictor of survival time (risk ratio of 0.12, 95% confidence interval 0.016-0.63; p=0.01). CONCLUSIONS: Cardiac surgery was effective in prolonging survival by managing high pulmonary blood flow; however, the indication for surgery should be carefully considered on a case-by-case basis, because the risk of sudden death remains even after surgery. Patients' families should be provided with sufficient information to make decisions that will optimise the quality of life for both patients and their families.

Surgical Intervention for Masticatory Muscle Tendon-Aponeurosis Hyperplasia Based on the Diagnosis Using the Four-Dimensional Muscle Model.

OBJECTIVES: The surgical target of Masticatory muscle tendon-aponeurosis hyperplasia (MMTAH) is the masseter or temporal muscle. In our clinic, the 4-dimentional muscle model (4DMM) has been used to decide if we should approach to the masseter or temporal muscle. The aim of this study is validate the clinical usefulness of 4DMM on the basis of the surgical results. METHODS: The 4DMM was constructed from the digital data of 3D-CT and 4-dimentional mandibular movements of the patients. It made us to able to visually observe the expansion rate of masticatory muscles at maximum mouth opening comparing to their length at closed mouth position. Fifteen patients were applied the 4DMM before the surgical treatment and 2 healthy volunteers were enrolled as control group. RESULTS: The expansion rate of temporal muscle at the maximum mouth opening in the patient group was significantly less than that in the control group (P < 0.05). On the other hand, the masseter muscles of all patients were expanded as same as the control group. Therefore the main cause of limitation of mouth-opening was suggested to be a contracture of the temporal muscle. Consequently, we performed successful bilateral coronoidectomy with no surgical intervention to the masseter muscles in all patients. CONCLUSION: The present 4DMM would be valuable modality to decide the target muscle of surgical treatment for patients with MMTAH. In this pathology, contracture of the temporal muscle seems to be main cause of limited mouth opening.

Aortic coarctation repair in neonates with intracardiac defects: the importance of preservation of the lesser curvature of the aortic arch.

BACKGROUND AND AIM: The aim of this study was to evaluate the mid-term outcomes of a strategy for repair of coarctation of the aorta (CoA) and hypoplastic aortic arch (HAA) with a modified, extended end-to-end repair that preserves the lesser curvature of the aortic arch in neonates with intracardiac defects. METHODS: We studied 21 neonates who underwent CoA repair and remote intracardiac repair (2000-2013). Fifteen patients had HAA, and six patients had no HAA. Follow-up ranged from 0.4 to 12.8 years (median, 7.5 years), and all patients underwent cardiac catheterization and blood pressure measurement in both the arms and legs. RESULTS: The overall median age at the time of CoA repair was seven days and the median age at the time of intracardiac defect repair was 18.6 months. There were no hospital deaths and one case had recoarctation (4.8%). The overall mean pressure gradient at the latest follow-up was 3.4 ± 5.7 mmHg. Critical deformation of arch geometry was not found. No patient had hypertension or an abnormal arm-leg gradient. There was no difference in the cardiac catheterization data or blood pressure between patients with and without HAA. CONCLUSIONS: A modified, extended end-to-end repair for CoA and HAA resulted in a low rate of recoarctation, no operative mortality, maintenance of a smooth rounded arch, and normal blood pressures in the arms and legs during mid-term follow-up. These results suggest that this technique may be acceptable for repair of CoA and HAA in neonates with intracardiac defects.

Replacement of the extracardiac conduit for infective endocarditis after a fontan operation.

We report the management of infective endocarditis after an extracardiac Fontan operation. Obstruction of the infected conduit and the associated pulmonary arterial embolism led to failure of the Fontan circulation. This was managed by completely removing both the infected conduit and emboli and replacing the conduit.

Anatomical repair of aortopulmonary window with anomalous origin of the right coronary artery from the pulmonary artery.

Aortopulmonary window (APW) with an anomalous origin of a coronary artery is extremely rare. We report surgical management of a four-week-old infant with the association of a distal type of APW and an anomalous origin of the right coronary artery (RCA) from the pulmonary artery. Complete anatomical correction comprising division of the great arteries and transferring the RCA as an autologous flap to the aortic defect was successfully performed.

Detection of buccal perimandibular neurovascularisation associated with accessory foramina using limited cone-beam computed tomography and gross anatomy.

PURPOSE: To investigate buccal perimandibular neurovascularisation associated with the mandibular accessory buccal foramina (ABF) which were detected using a limited cone-beam computed tomography (limited CBCT). METHODS: Five Japanese cadaveric mandibles had been examined using helical CT to investigate the presence or absence of ABF. Two mandibles indicating the presence of AMF were examined more minutely using a limited CBCT. Following the three-dimensional radiological observation of ABF, the mandibles were removed from the cadavers and dissected with referring to the findings of AMF on the limited CBCT images. RESULTS: Four ABF of the three mandibular sides, which were depicted with limited CBCT, had different perimandibular neurovascularisation. Three accessory foramina were associated with the following arteries: a branch of the submental, facial, and buccal artery, and one was associated with a branch of the mental nerve. A branch of the mental nerve re-entered the mandible through the accessory foramen after it exited from a mental foramen. CONCLUSION: Limited CBCT is useful for pre-operative three-dimensional assessment of mandible since high-resolution analysis demonstrates not only the skeletal conditions but also the assessment and suggestions of perimandibular neurovascularisation.

Intraoperative Findings of an Atypical Type II Endoleak from an Artery within the Aneurysmal Wall after Endovascular Aneurysm Repair.

A 75-year-old man underwent emergent endovascular aortic repair for a ruptured abdominal aortic aneurysm. Two years later, computed tomography revealed aneurysm enlargement with endoleaks. Next, late open conversion was performed. Intraoperatively, we detected a spurting type II endoleak from an artery within the aneurysmal wall, which was unconnected to any branch vessels outside the aneurysm, and surgical ligation and sacotomy was performed uneventfully. To our knowledge, this is the first report to intraoperatively identify a type II endoleak from an artery within the aneurysm wall. Even for atypical type II endoleak, such as this case, open surgical repair should be effective.

Axonal Projections from Middle Temporal Area to the Pulvinar in the Common Marmoset.

The pulvinar, the largest thalamic nucleus in the primate brain, has connections with a variety of cortical areas and is involved in many aspects of higher brain functions. Among cortico-pulvino-cortical systems, the connection between the middle temporal area (MT) and the pulvinar has been thought to contribute significantly to complex motion recognition. Recently, the common marmoset (Callithrix jacchus), has become a valuable model for a variety of neuroscience studies, including visual neuroscience and translational research of neurological and psychiatric disorders. However, information on projections from MT to the pulvinar in the marmoset brain is scant. We addressed this deficiency by injecting sensitive anterograde viral tracers into MT to examine the distribution of labeled terminations in the pulvinar. The injection sites were placed retinotopically according to visual field coordinates mapped by optical intrinsic imaging. All injections produced anterograde terminal labeling, which was densest in the medial nucleus of the inferior pulvinar (PIm), sparser in the central nucleus of the inferior pulvinar, and weakest in the lateral pulvinar. Within each subnucleus, terminations formed separate retinotopic fields. Most labeled terminals were small but these comingled with a few large terminals, distributed mainly in the dorsomedial part of the PIm. Our results further delineate the organization of projections from MT to the pulvinar in the marmoset as forming parallel complex networks, which may differentially contribute to motion processing. It is interesting that the densest projections from MT target the PIm, the subnucleus recently reported to preferentially receive direct retinal projections.

Anatomical characteristics of the mandibular lingual foramina observed on limited cone-beam CT images.

OBJECTIVES: The study aimed to investigate the regional frequency and anatomical properties of mandibular lingual foramina. MATERIAL AND METHODS: The regional frequency of the lingual foramina was investigated using limited cone-beam computed tomographic images of mandibles obtained from 190 examinations of 181 patients. The mesio-distal position of the lingual foramina was classified into 17 areas of the midline area and each tooth area. The vertical position was assessed from the positional relationship between the lingual foramina and mandibular canals. Additionally, anastomoses of the lingual canals from the lingual foramina to mandibular canals were observed on the images. RESULTS: One hundred and fifty-four lingual foramina were observed. The highest regional frequency was recognized in the midline area followed by second premolar and canine area. Plural lingual foramina were observed only in the midline areas. No lingual foramina were observed in the superior area of the mandibular canals. Thirty-one lingual foramina showed anastomoses between the lingual canals and mandibular canals. CONCLUSION: Information on the high regional frequency of lingual foramina in the second premolar area would be clinically significant to avoid life-threatening incidents because of the possible presence of an artery. It is therefore important to confirm the location of lingual foramina.

Nationwide Increase in Complex Congenital Heart Diseases After the Fukushima Nuclear Accident.

Background After the Chernobyl nuclear accident in 1986, an increase in the incidence of congenital heart disease ( CHD s) in the neighboring countries was reported. In 2011, Japan experienced the Great East Japan Earthquake and the nuclear accidents at Fukushima. However, a nationwide study of their effects has not been conducted yet. Methods and Results We used data covering the period between 2007 and 2014 from the annual surveys conducted by the Japanese Association for Thoracic Surgery, which included almost all of the operations pertaining to 46 types of CHD s in Japan. CHD s were divided into 2 groups based on complexity, the time of occurrence during heart development, and age at operation. We estimated the change in the number of the operations per 100 000 live births between pre- and postdisaster using a negative binomial generalized linear mixed model. Overall, a significant 14.2% (95% CI, 9.3-19.4) increase in the number of operations for complex CHD s in neonates and infants per 100 000 live births was found, whereas those performed for patients of 1 to 17 years old showed no significant change during the study period. Conclusions The number of operations for complex CHD s in neonates and infants in Japan significantly increased after the massive disaster, and its level was maintained thereafter. The number of operations for complex CHD was not equal but closely correlated to the live birth prevalence of complex CHD s. Therefore, some meaningful increase in the live birth prevalence can be assumed; however, the precise cause of the increase is unknown.

An aneurysm at the cannulation site discovered 40 years after cardiac surgery: report of a case.

We report the successful surgical treatment of a pseudoaneurysm of the ascending aorta in a 45-year-old man who underwent surgical closure of a ventricular septal defect at the age of 5. A computed tomography scan ordered for the investigation of a pulmonary mass happened to detect a pseudoaneurysm (20 mm diameter). The pseudoaneurysm protruded anteriorly from the ascending aorta at the previous aortic cannulation site. The ascending aorta, including the lesion, was replaced with a prosthetic graft uneventfully. The cause of the pseudoaneurysm was considered iatrogenic, since he had no prior history of postoperative mediastinitis or blunt chest trauma. A computed tomography scan is a useful means to detect a mass on the ascending aorta following cardiac surgery, and it provides important information to help define a surgical strategy.

Dental fiberscope with navigation system for endodontic treatments.

We developed a dental fiberscope with a navigation system. The aim of this study is to direct the position of the tip of the endoscope fiber in the root canal via our navigation system. The distinguishing characteristic of our system is that it could be particularly practical in narrow spaces, such as those involving endodontic treatment typical of root canals. We were subsequently able to precisely indicate the relation of the position between the device and the teeth on the 3D model on the monitor. We inspected our navigation system using both the phantom model and the reconstructed 3D model. From this we could comprehend the relation of the position between the teeth and the device, and aim precisely at the lesion. If we are able to realize the correct position of the endoscope, we can safely and accurately deliver laser irradiation to the lesion. Consequently, the application of the endoscopic navigation system could increase the success rate for root canal treatments with recalcitrant lesions.

Translocation of dilated pulmonary artery for relief of bronchial compression associated with ventricular septal defect.

Bronchial compression due to a dilated pulmonary artery is a troublesome problem in the surgical management of infants or children with congenital heart disease. We experienced an infantile case of ventricular septal defect and prolonged respiratory insufficiency caused by right bronchial compression and left pulmonary hypoplasia. Anterior translocation of the dilated right pulmonary artery and intracardiac repair succeeded in relieving the bronchial compression and improving left pulmonary function. We advocate that this procedure is useful for bronchial compression with congenital heart disease and maldevelopment of the lung.

Posterior mediastinal angioleiomyoma: report of a case.

We describe a case of mediastinal angioleiomyoma in an asymptomatic 72-year-old man, who was admitted to our hospital for a mediastinal tumor discovered during an annual medical examination. The tumor was evaluated by computed tomography (CT) and magnetic resonance imaging (MRI). Unenhanced CT scans demonstrated a tumor that was adjacent to the descending aorta. The tumor was partially enhanced in the early phase of contrast-enhanced CT, and in the late phase there was additional tumor enhancement. With MRI, the tumor displayed a homogeneous low signal intensity on the T1-weighted image and a homogeneous very high signal intensity on the T2-weighted image. Contrast-enhanced MRI demonstrated the same enhancement pattern as CT. The examination results led to a preoperative diagnosis of posterior mediastinal hemangioma, and the patient underwent surgery. The tumor originated from the supreme intercostal vein, and was diagnosed as an angioleiomyoma by histopathologic examination. Because mediastinal angioleiomyomas are very rare, they are difficult to diagnose preoperatively. However, we believe that CT and MRI can be of significant help in the differential diagnosis.

Cardiotrophin-1 is a prophylactic against the development of chronic hypoxic pulmonary hypertension in rats.

BACKGROUND: Cardiotrophin-1 (CT-1) reduces arterial blood pressure by activating nitric oxide synthesis. This study attempted to elucidate the effect of CT-1 on pulmonary arteries of pulmonary hypertensive rats. METHODS: Pulmonary hypertension was induced in rats in a hypoxic chamber containing 10% to 11% oxygen. Rats kept in the hypoxic environment received either recombinant mouse CT-1 at a concentration of 50 micro g/kg (CT-1+hypoxia group, n = 21) or phosphate-buffered saline (hypoxia group, n = 30) once per day. Control rats housed in room air also received either the equivalent concentration of CT-1 (CT-1+normoxia group, n = 18) or phosphate-buffered saline (normoxia group, n = 39). Pulmonary arterial pressure, pulmonary vasorelaxation, and ventricular hypertrophy were measured. RESULTS: The mean pulmonary arterial pressures were as follows (from lowest to highest; p values are relative to the hypoxia group): normoxia group (20.3 +/- 4.0 mm Hg, p < 0.0001), CT-1+normoxia group (21.1 +/- 2.4 mm Hg, p < 0.0001), CT-1+hypoxia group (27.9 +/- 4.1 mm Hg, p = 0.0019), and hypoxia group (33.9 +/- 6.6 mm Hg). The endothelium-dependent vasorelaxation value was largest in the normoxia group (59.5% +/- 17.4%, p < 0.0001), with it decreasing in the other groups in the following order (p values are relative to the hypoxia group): CT-1+normoxia group (52.8% +/- 15.5%, p = 0.0005), CT-1+hypoxia group (42.3% +/- 14.8%, p = 0.0061), and hypoxia group (17.4% +/- 4.8%). Right ventricular hypertrophy was significant only in the hypoxia group. CONCLUSIONS: Our results demonstrate that treatment with CT-1 in a chronic hypoxic pulmonary hypertension model protects the endothelial function of the pulmonary artery; decreases pulmonary arterial pressure; and attenuates right ventricular hypertrophy.

Nitric oxide formation and plasma L-arginine levels in pulmonary hypertensive rats.

The elevation of plasma L-arginine levels stimulates nitric oxide (NO) synthesis, but the underlying mechanisms are not yet understood. We examined the role of physiological changes in pulmonary arteries on endogenous NO production. Male Wistar rats were divided into following groups: (1) control rats receiving normal water orally, (2) ARG rats receiving L-arginine water orally, (3) MCT rats injected with monocrotaline (MCT) on day 0 and receiving normal water orally, and (4) MCT+ARG rats injected with MCT on day 0 and receiving L-arginine water orally. The rats were studied after 23 days of dietary intervention. In MCT+ARG rats, supplemental L-arginine exhibited a significant pulmonary vasodilatory effect, as shown by a decreased pulmonary arterial pressure (PAP) (P<0.001), decreased right ventricular hypertrophy (P<0.01), and improved endothelium-dependent relaxation (P<0.01). Also L-arginine inhibited the elevation of plasma endothelin-1 (P<0.01). Oral L-arginine administration increased plasma L-arginine levels about twofold, but in only MCT+ARG rats (i.e., not in ARG rats) did the urinary nitrate excretion significantly increase (P<0.05), which is an indicator of endogenous NO formation. Oral administration of L-arginine is effective against pulmonary vascular remodeling. The data also suggest that the initial elevation of PAP is important for the induction of endogenous NO synthesis.

Cardiac hemangioma of the left atrial appendage: CT and MR findings.

Cardiac hemangiomas are rare, benign primary cardiac neoplasms. We describe the CT and MR imaging findings of a cardiac hemangioma arising from the myocardium of the left atrial appendage and protruding into the pericardial cavity. The tumor displayed homogenous density on CT, heterogeneous signal intensity on MR, and inhomogeneous enhancement after intravenous contrast administration. The hemangioma in this case was difficult to differentiate from other myocardial or a pericardial tumor.