Multicenter prospective study of the efficacy of stereomicroscopic on-site evaluation in endoscopic ultrasound-guided tissue acquisition in patients with pancreatic cancer.

OBJECTIVE: In sample isolation processing by stereomicroscopy (SIPS), a technique used to assess the quality of specimens collected during endoscopic ultrasound (EUS)-guided tissue acquisition (EUS-TA), the cutoff value of stereomicroscopically visible white core (SVWC) (≥11 mm) indicates high diagnostic sensitivity. However, the procedure of SIPS is complicated and time-consuming. Therefore, we devised the stereomicroscopic on-site evaluation (SOSE), a new rapid assessment method that is simpler than SIPS and only determines if the SVWC cutoff value is attained. We aimed to examine the usefulness of SOSE in a multicenter, prospective setting. METHODS: Seventy patients from multiple institutions with solid pancreatic masses suspected to be pancreatic cancer were included. EUS-TA was performed using a 22-gauge Franseen needle. SVWCs were measured on-site using stereomicroscopy. The primary outcome was the sensitivity of SVWC cutoff value in EUS-TA with SOSE. RESULTS: The total number of punctures was 214 and SOSE was performed on 150 punctures. The SVWC cutoff value collection rate was 100% per lesion, with 80% in the first pass, 79% in the second pass, and 78% per puncture in all passes. The median time taken to determine the SVWC cutoff value for SOSE was 47 s. The sensitivity of the SVWC cutoff value was 93.2% for histology and 96.6% for cytology + histology. The per-lesion accuracy of pathological diagnosis reached the highest level (98.6%) at the second puncture. CONCLUSIONS: SOSE showed high diagnostic sensitivity and may be a new rapid assessment method for the diagnosis of malignant pancreatic cancer using EUS-TA.

Endoscopic Balloon Dilation for Benign Bilioenteric Stricture: Outcomes and Factors Affecting Recurrence.

BACKGROUND: Balloon dilation (BD) is a simple, effective procedure for postoperative benign bilioenteric strictures (BBESs). Factors associated with BBES recurrence after endoscopic BD have not been studied adequately. This study examined the outcomes and 1-year recurrence factors in patients with BBES who underwent endoscopic BD. METHODS: Patients who underwent endoscopic BD as an initial treatment between April 2008 and March 2017 were retrospectively assessed. The median time to recurrence of BBES (RBBES) and recurrence factors were evaluated. RESULTS: The study group comprised 55 patients (median age 72 years). The rate of RBBES was 52.7% (29/55), and the median time to RBBES was 2.78 years (95% confidence interval [CI] 1.17-4.40). RBBES was observed in 32.7% (18/55) within 1 year after endoscopic BD. The significant factors associated with recurrence within 1 year, revealed by multivariate analysis, were: postoperative bile leak (p = 0.001; hazard ratio [HR] 10.94; 95% CI 2.47-48.39); BBES onset within 6 months, postoperatively (p = 0.013; HR 6.18; 95% CI 1.46-26.21); no intrahepatic stones (p = 0.049; HR 3.05; 95% CI 1.01-9.22); and remaining balloon waist (p = 0.005; HR 5.71; 95% CI 1.69-19.31). The median time to RBBES was significantly shorter in patients with these recurrence factors (0.88 years vs. not reached, p = 0.004). Patients exhibiting at least two recurrence factors were significantly more likely to experience recurrence (p < 0.001). CONCLUSION: Endoscopic BD is effective for BBES, especially for patients with no recurrence factors. Consideration of endoscopic BD and additional treatment may be necessary for patients with recurrence factors.

Heparin Induces the Mobilization of Heart-Derived Multipotent Mesoangioblasts During Cardiac Surgery With Cardiopulmonary Bypass or Cardiac Catheterization.

BACKGROUND: We previously identified circulating mesoangioblasts (cMABs), a subset of mesenchymal stem cells that express cardiac mesodermal markers, in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). We also found that hepatocyte growth factor (HGF) is upregulated during cardiac surgery with CPB in humans, and induces MAB-like cell mobilization in rodents. These results strongly suggest that heparin induced MAB mobilization via HGF upregulation. Here, we tested this hypothesis in patients undergoing cardiac surgery or cardiac catheterization. We also examined whether human cMABs are derived from the heart.Methods and Results:Plasma HGF levels were determined by ELISA. Mononuclear cells isolated from blood samples were cultured on fibronectin-coated dishes, and outgrowing cMAB colonies were counted. We first confirmed that HGF upregulation and cMAB mobilization were observed before the start of CPB, excluding the possibility that CPB is the primary inducer of cMAB mobilization. We then examined patients undergoing cardiac catheterization and found that heparin significantly increased plasma HGF levels and the number of cMAB colonies in a dose-dependent manner. The results of simultaneous blood sampling from the aortic sinus, coronary sinus, and right atrium were consistent with the notion that human cMABs are derived from the heart. CONCLUSIONS: Human cMABs are mobilized by heparin injection during cardiac surgery or cardiac catheterization, presumably via HGF upregulation.

Segmental clamp and distal perfusion technique for reducing myocardial ischemia during coronary onlay grafting on a beating heart.

We present a segmental clamp with distal perfusion technique to reduce myocardial ischemia during onlay grafting, on a beating heart. After a proximal coronary arteriotomy for 2-3 cm, the distal artery is perfused through a cannula, with femoral arterial blood (distal perfusion with external shunt). During proximal and distal coronary snare clamping with distal perfusion, onlay anastomosis is performed, from the heel toward the point of cannula insertion. We then move the proximal clamp to the onlay area and open the graft, to get early proximal coronary reperfusion. The arteriotomy is extended, and this procedure is repeated to achieve complete beating heart onlay anastomosis. We safely performed this procedure on the beating heart off-pump or on-pump in 95 patients with no perioperative myocardial infarction, no intraoperative hemodynamic deterioration, no 30-day mortality. This technique reduces regional myocardial ischemic and secures the safety for onlay grafting on the beating heart.

Granulocyte colony-stimulating factor does not enhance recruitment of bone marrow-derived cells in rats with acute myocardial infarction.

Despite the potential benefit of granulocyte colony-stimulating factor (G-CSF) therapy in patients with acute myocardial infarction (MI), the efficacy of G-CSF in regenerating the heart after MI remains controversial. The authors hypothesize that the limited efficacy of G-CSF is related to its inhibitory effect on recruitment of bone marrow-derived cells (BMCs) to the infarcted tissue. MI was induced in rats with intrabone marrow-bone marrow transplantation from syngenic rats expressing green fluorescence protein to track BMCs. G-CSF was administered for five days after the onset of MI. G-CSF increased the number of CD45(+) cells in the peripheral circulation but did not increase their recruitment to the heart. G-CSF had no effect on myocardial stromal-derived factor-1 alpha and chemokine (C-X-C motif) receptor 4 (CXCR4) expression in mononuclear cells in the peripheral blood and CXCR4(+) cells in the heart. G-CSF had no effect on angiogenesis, myocardial fibrosis or left ventricular function four weeks after MI. These results suggest that G-CSF mobilizes BMCs to the peripheral circulation but does not increase recruitment to the infarcted myocardium despite preservation of the stromal-derived factor-1 alpha/CXCR4 axis.

Possible internal viral shedding and interferon production after clinical recovery from COVID-19: Case report.

A 70-year-old man underwent off-pump coronary artery bypass grafting 28 days after his recovery from coronavirus disease 2019 (COVID-19), which was confirmed by a negative polymerase chain reaction (PCR) test result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a nasopharyngeal swab. The PCR test result was also negative for nasopharyngeal sampling 5 days prior to the surgery. However, his redundant saphenous vein and sputum through the endotracheal tube that was taken on the operative day showed the presence of SARS-CoV-2 by PCR. Immunohistochemical analysis of Spike and Nucleoprotein of the saphenous vein showed small clusters of each antigen-positive speckle. Ultrastructural imaging of the saphenous vein showed virus-like particles. The cell-based assay suggested that the patient's serum contained a higher concentration of type-I interferons than that of healthy control sera. These observations suggest that internal viral shedding and, to some extent, innate immune responses continue after COVID-19 recovery.

Comprehensive Pain Control Strategy in Minimally Invasive Mitral Valve Repair.

PURPOSE: The effect of our comprehensive strategy to reduce pain after minimally invasive mitral valve repair through a right mini-thoracotomy was assessed retrospectively. METHODS: Our comprehensive strategy constituted the following: planned rib cutting to avoid rib injury, sufficient intercostal muscle division to mobilize the cut rib, limiting the number of intercostal ports, avoiding nerve entrapment, continuous extra-pleural intercostal nerve block, and regular use of oral non-steroidal anti-inflammatory drugs. We compared patients treated with this comprehensive strategy (Group S, n = 13) and patients before this strategy was implemented (Group C, n = 13). We used a numerical rating scale (NRS) as a pain scale during the first 3 days postoperatively. RESULTS: The average NRS was significantly lower in Group S (0.82 ± 0.49) than in Group C (2.40 ± 1.46) (P <0.01). The maximum NRS was also significantly lower in Group S (3.23 ± 1.17) than in Group C (5.69 ± 2.43) (P <0.01). The number of patients using additional single-dose analgesic were significantly less in Group S (23.1%) than in Group C (84.6%) (P <0.01). CONCLUSION: Our comprehensive pain control strategy effectively reduced postoperative pain in minimally invasive mitral valve repair.

Midterm Performance of the Autologous Adventitial Overlay Method in Aortic Surgery.

BACKGROUND: We developed an adventitial overlay method for reinforcing aortic anastomoses. This study evaluated the midterm morphological and clinical outcomes of this method. METHODS: We harvested and prepared adventitia from a resected aneurysm or dissected aortic wall and performed aortic repair using the adventitial overlay method. At the midterm follow-up, we examined the differences among overlay, inversion, and felt-sandwich (FS) methods by evaluating the morphology of the anastomosis using computed tomography (CT) scans. Moreover, we performed macroscopic evaluation of one patient who required a second operation. RESULTS: Between May 2009 and April 2020, 160 consecutive patients (104 males, 56 females; mean age, 68.6 ± 11; range, 39-88 years) underwent thoracic aortic surgery. The overlay technique was successfully performed in 84 cases. The anastomosis sites of the overlay method maintained their morphology without any clinical complications. The inner diameter ratio of anastomosis/graft was measured using CT, which revealed that the overlay method was not significantly different from inversion and was significantly larger than the FS method. There was no anastomotic stenosis in the proximal or distal overlay anastomosis. Only one patient required a second operation for an enlarged aneurysm of the distal false lumen. We observed that the proximal overlaid adventitia was smoothly attached to the native lumen and was macroscopically indistinguishable from the original intima. CONCLUSIONS: This study showed the midterm stability of the overlay technique. The midterm outcome was clinically acceptable. No anastomotic stenosis or pseudoaneurysm formation in either the true aortic aneurysm or dissection cases was observed.

Utility of Ultrasonographic Assessment of Distal Femoral Arterial Flow during Minimally Invasive Valve Surgery.

PURPOSE: To evaluate the utility of ultrasonographic assessment of blood flow to the lower limb below the cannulation site in minimally invasive cardiac surgery (MICS). METHODS: Twenty-two patients who underwent ultrasonographic assessment in MICS were reviewed retrospectively. In all patients, the right femoral artery was used for arterial cannulation. Ultrasonographic assessment was performed using a 15-MHz ultrasonography small probe, and regional oxygen saturation was monitored by near-infrared spectroscopy (NIRS). RESULTS: The mean flow velocity at the distal side of the cannulation site was 46.2 ± 25.4 cm/s. In six patients, a >40% decreased from baseline regional oxygen saturation was observed. In five of the six patients, the flow velocity was very slow, and spontaneous echo contrast was also observed in three cases. Their regional oxygen saturation was improved rapidly after distal leg perfusion. In the remaining case, the flow velocity was not decreased. In another one case, the stenosis at the cannulation site was detected after decannulation and repaired immediately. No limb ischemic complications were observed in this series. CONCLUSION: Ultrasonographic assessment combined with the NIRS monitoring is useful to prevent lower limb ischemic complications after femoral arterial cannulation in MICS.

Cholecystitis after Placement of Covered Self-Expandable Metallic Stents in Patients with Distal Malignant Biliary Obstructions.

BACKGROUND/AIMS: Cholecystitis can occur after the placement of covered self-expandable metallic stents for distal malignant biliary obstructions. We aimed to identify risk factors for cholecystitis following covered self-expandable metallic stent placement. METHODS: We investigated risk factors related to cholecystitis following covered self-expandable metallic stent placement in 118 patients with distal malignant biliary obstructions between January 1, 2015 and April 30, 2019. Endoscopic assessments and tumor invasion to the arteries feeding the gallbladder were determined by a pancreaticobiliary endoscopist and a radiologist, respectively. RESULTS: The median patient age was 72 years (men, 61.0%). The flow of the contrast agent into the gallbladder and tumor involvement in the orifice of the cystic duct were observed in 35 (29.7%) and 35 (29.7%) patients, respectively. During the observation period (median, 179 days), cholecystitis occurred in 18 (15.3%) patients. Multivariate analysis revealed the flow of the contrast agent into the gallbladder (p=0.023) and tumor involvement in the orifice of the cystic duct (p=0.005) as significant independent risk factors associated with cholecystitis. CONCLUSION: The flow of the contrast agent into the gallbladder and tumor involvement in the orifice of the cystic duct are potential independent risk factors for cholecystitis following the placement of covered self-expandable metallic stents. A follow-up prospective study is warranted to validate their influence.

Commissure enhancement technique in aortic valve repair.

Sinotubular junction enlargement is one of possible causes of aortic valve regurgitation. However, there is no appropriate technique for sinotubular junction diameter reduction in aortic valve repair in a patient without disease of the ascending aorta or sinus of Valsalva. Herein, we report a simple commissure enhancement technique comprising the placement a horizontal mattress suture buttressed with felt at the sinotubular junction level in the commissure area. This technique results in the relocation of the commissure to the inner side, and a reduction in the diameter of the sinotubular junction.

Mitral valve stenosis caused by abnormal pannus extension over the prosthetic ring and leaflets after Duran ring mitral annuloplasty.

We treated a 61-year-old woman with mitral stenosis caused by pannus formation after Duran ring annuloplasty. Pannus overgrowth on the ring with extension onto both leaflets narrowed the mitral orifice and severely restricted the mobility of the valve leaflets. Mitral valve replacement with a St. Jude Medical mechanical heart valve prosthesis was successfully performed, and the postoperative course was uneventful. Patients undergoing Duran ring annuloplasty should be followed up with the consideration of possible mitral stenosis caused by pannus extension, as the cause for pannus formation remains unclear.

Intimal regeneration after coronary endarterectomy and onlay grafting in coronary artery bypass grafting.

OBJECTIVES: Coronary onlay grafting, with or without endarterectomy, has been widely used for the treatment of diffuse lesions. Recent studies have demonstrated excellent long-term patency and favorable remodeling of onlay anastomosis; however, the underlying mechanisms remain unknown. Here, we describe the mechanism of intimal regeneration based on postmortem pathological evaluation of a patient who had undergone onlay grafting with coronary endarterectomy. METHODS: The onlay anastomosis was analyzed using a combination of immunohistological stainings, namely, H&E, vimentin, α-SMA, factor VIII, and Ki-67, to identify the source and mechanism of intimal regeneration after onlay grafting with endarterectomy. RESULTS: Our results suggest that the regenerated endothelium derives from the smooth muscle cells of the endarterectomized media of the coronary artery and that it circumferentially covers the internal lumen of the arterial graft. CONCLUSIONS: Intimal regeneration, derived from the smooth muscle cells of the endarterectomized coronary artery that proliferate toward the graft lumen, may be a key mechanism that underlies the observed favorable remodeling after onlay grafting during coronary endarterectomy.

Perioperative coronary artery spasm in off-pump coronary artery bypass grafting and its possible relation with perioperative hypomagnesemia.

PURPOSE: We experienced 3 cases of serious perioperative coronary artery spasm in off-pump coronary artery bypass grafting (OPCAB). In consideration of the causes, we directed our attention to hypomagnesemia, one of the triggers of coronary artery spasm. This study was performed to confirm the tendency to hypomagnesemia in OPCAB. METHODS: First, we report 3 patients having severe coronary artery spasm immediately after OPCAB with consideration of the causes. Second, serial magnesium (Mg) value (xylidyl blue method, normal 1.9-3.1 mg/dl) was measured in 45 consecutive patients with OPCAB between April and October 2002, 1) before starting the operation, and 2) after the patient's entrance into the intensive care unit. RESULTS: Preoperative and postoperative values of Mg (mg/dl) were 2.1+/-0.3, 1.7+/-0.3, respectively (p < 0.01). Postoperative incidence of hypomagnesemia was as high as 89% of the patients (40 out of 45 patients). In this study and thereafter, we corrected hypomagnesemia with magnesium sulfate during and after OPCAB, and no perioperative coronary artery spasm occurred. CONCLUSION: Hypomagnesemia, one of the triggers of coronary artery spasm, is very common in OPCAB. We strongly recommend the correction of hypomagnesemia during and after OPCAB for the prevention of perioperative coronary artery spasm.

Cardiac angiosarcoma with right atrial perforation and cardiac tamponade.

Primary cardiac angiosarcoma is a rare tumor associated with a poor prognosis. We report a case of a 59-year-old woman with right atrial angiosarcoma presenting with cardiac tamponade due to right atrial perforation. She underwent urgent surgical resection of the tumor. However, the patient died 68 days after surgery due to local recurrence. An effective treatment for cardiac angiosarcoma has not yet been established. However, more aggressive treatment with a combination of surgery, radiation, chemotherapy and IL-2 should be considered.

Traumatic ventricular septal rupture associated with rapid progression of heart failure despite low Qp/Qs ratio: a case report.

BACKGROUND: Ventricular septal rupture (VSR) secondary to blunt chest trauma is rare and associated with a diverse range of symptoms and clinical courses as well as disease severity. We present a case of traumatic VSR in which rapid progression of heart failure was observed in spite of relatively low pulmonary to systemic blood flow (Qp/Qs) ratio. CASE PRESENTATION: A 40-year-old male was transported to the emergency department approximately 12 h after blunt chest trauma. VSR was diagnosed by echocardiography, and right heart catheterization revealed a Qp/Qs ratio of 1.52. Although medical treatment was initially attempted, subsequent rapid progression of heart failure necessitated emergent surgical repair of VSR. CONCLUSIONS: Because small, asymptomatic VSR often close spontaneously, surgical repair of traumatic VSR is indicated when the shunt rate is relatively large or heart failure is present. However, the present case highlights the need to consider emergent surgical repair of traumatic VSR, even when the shunt rate is relatively small.

Surgical treatment of pseudoaneurysm of the sinus of valsalva after aortic valve replacement for active infective endocarditis.

Pseudoaneurysm is an uncommon and serious complication of infective endocarditis (IE). It is often fatal because of its rapid progress, high rates of rupture and recurrence, and worsening effects on the systemic condition. We report the rare case of a patient who developed a pseudoaneurysm of the sinus of Valsalva two months after emergency aortic valve replacement for active IE. At the previous operation, we had directly closed a small fistulous hole in the non-coronary sinus of Valsalva using two mattress sutures with autologous pericardial pledgets, because the tissue surrounding the hole did not appear to be infected on visual inspection. A pseudoaneurysm developed from this portion due to detachment of sutures. If the fistula had been completely resected during the first surgery instead of performing a simple closure, the pseudoaneurysm of the sinus of Valsalva would not have formed. However, the primary aim of the first emergency surgery was to spare the life of a critically ill patient. In the second surgery, the pseudoaneurysm was completely resected with the aortic wall--including the non-coronary sinus of Valsalva and the communicating hole. Then, patch plasty of the non-Valsalva sinus was successfully performed.

Surgical treatment for coronary artery aneurysm.

Two successful cases of the surgical treatment for coronary artery aneurysm (non-Kawasaki disease) were reported. The first case had a saccular aneurysm on the left circumflex coronary artery (LCx) #14. Resection of the LCx aneurysm was performed subsequent to single vessel coronary artery bypass grafting (CABG) to the distal portion of LCx#14 under the cardioplegic cardiac arrest. The second case had aneurysms on both the left anterior descending artery (LAD) #7 (fusiform) and the LCx#11 (saccular). After double vessel CABG to LAD#7 and LCx#11, ligation or resection of two aneurysms was performed successfully. Postoperative courses have been uneventful with good angiographic results achieved. Since these surgical procedures demonstrated safety, the patients are expected to achieve a good long-term prognosis.

Assessment of ascending aorta using epiaortic ultrasonography during off-pump coronary artery bypass grafting.

BACKGROUND: Use of an aortic partial clamp for proximal anastomosis during off-pump coronary artery bypass is known to increase the risk of fatal complications. The purpose of this study was to assess the management of the ascending aorta evaluated with epiaortic ultrasonography during off-pump coronary artery bypass. METHODS: Intraoperative ultrasonography of the ascending aorta with a 10-MHz probe was performed consecutively in 155 patients undergoing off-pump coronary artery bypass between August 1999 and July 2001. The findings from ultrasonography, surgical modifications, and operative results were analyzed. RESULTS: In 54 patients (34.8%), epiaortic ultrasonography showed atherosclerotic findings in the anterior side of the ascending aorta (group A). The remaining 101 patients had either normal findings or atherosclerotic findings in only the posterior side (group NA). A proximal anastomosis to the aorta was preoperatively planned in 117 patients (group A, 42; group NA, 75). In group A, a graft modification without clamping was implemented in 29 patients (24.8% of 117 patients), whereas the clamp site was modified to a different segment in 13 patients (11.1% of 117 patients). In all 75 patients in group NA, partial clamping was used in the standard fashion. There were no cerebral infarctions or operative deaths related to partial clamping. However, aortic dissection occurred in 1 patient in group NA. CONCLUSIONS: In 35% of patients undergoing off-pump coronary artery bypass, epiaortic ultrasonography identified atherosclerotic findings in the anterior wall of the ascending aorta. This study suggests that revascularization without aortic manipulation during off-pump coronary artery bypass is indicated in as many as 25% of patients.