Clinicopathological study on penetrating atherosclerotic ulcers and aortic dissection: distinct pattern of development of initial event.

An intimal tear is responsible for the development of aortic dissection (AD). Plaque rupture is thought to progress to a penetrating atherosclerotic ulcer (PAU). However, the influences of mechanical stress and atherosclerosis on the intimal tear of AD and plaque rupture of PAU have not been fully understood. We enrolled 27 patients with AD [67.6 ± 11.2 years, female/male (F/M) 12/15] and 10 patients with PAU (71.0 ± 8.64 years, F/M 2/8) who underwent aortic reconstructive surgery in our hospital between 2007 and 2011. We analyzed the clinical data and morphological features of these patients and discuss the role of mechanical stress in the initial event. On clinical examination, hypertension was frequently observed in the patients of both the AD (77.8 %) and PAU groups (90.0 %), while hypercholesterolemia was significantly more prevalent in the PAU group (90.0 %) than in the AD (22.2 %) group. Most lesions of AD (96.3 %) were found in the ascending aorta up to the aortic arch, while those of PAU (90.0 %) were found in the descending and abdominal aortas. On pathological examination, the entrance tear was found in 21 (77.8 %) of the 27 patients with AD, and histologically comprised nonatherosclerotic intima and media. In contrast, the entrance tear was considered as plaque ulcer in 8 (80.0 %) of the 10 patients with PAU. The patients with PAU showed a significantly higher prevalence of soft plaque, complicated lesions, and medial fibrosis than those with AD, whereas patients with AD showed no complicated lesions and had a significantly higher prevalence of cystic medial necrosis than those with PAU. The present study suggests that less atherosclerosis and impairment of media could proceed to intimal tear formation in AD and that the disruption of the fibrous cap could cause the plaque ulcer of PAU.

[Coronary Artery Bypass Grafting and Biventricular Pacing for Severe Heart Failure due to Dilated Cardiomyopathy].

A 57-year-old man was diagnosed with dilated cardiomyopathy and coronary stenosis. His electrocardiogram showed a complete left bundle branch block and a prolonged QRS interval. As appropriate medical therapy improved his symptoms, he did not visit out-patient clinic after discharge. A year later, he presented with exertional chest oppression and was readmitted with severe heart failure. Although medical therapy was provided, his condition did not improve. Left ventricular systolic dysfunction and stenosis of the left anterior descending artery were aggravated. We performed coronary artery bypass grafting and biventricular pacing with surgical epicardial leads, which led to improvement in left ventricular systolic function. We consider that biventricular pacing with surgical epicardial leads is a potential option in cases of open heart surgery requiring cardiac resynchronization therapy for severe left ventricular systolic dysfunction.

[Surgical excision of left atrial myxoma shortly after cerebral embolism;report of a case].

A 48-year-old male visited the emergency room suffering from acute dysarthria and right hemiplegia. Brain magnetic resonance imaging (MRI) revealed multiple cerebral infarctions. Echocardiography showed a mass in the left atrium. He was diagnosed with cerebral embolism due to left atrial myxoma. Open heart surgery immediately after the attack is generally considered contraindicated because of such problems as hemorrhagic infarction or brain edema. However, relapse of embolism may make the condition worse and miss the timing of surgery. Eventually, we electively performed excision of the myxoma 20 days after the onset of cerebral infarction. The postoperative course was uneventful. This is a report about a rare case of open heart surgery shortly after the attack. The indication and the appropriate timing of open heart surgery following cerebral embolism were discussed.

A case of type-2 endoleak from a bronchial artery after endovascular aortic repair for Kommerell diverticulum.

We describe a case of type-2 bronchial artery endoleak after endovascular aortic repair of Kommerell diverticulum (KD) involving right-sided aortic arch and aberrant left subclavian artery (LSA). A 68-year-old woman underwent an endovascular repair of KD with an aberrant LSA in our hospital. Follow-up computed tomography (CT) at 6 months after the procedure showed an endoleak. Digital subtraction angiography revealed a type-2 endoleak from a bronchial artery, but no type-1 or type-2 endoleak from the aberrant left subclavian artery. We performed coil embolization of the KD and the left subclavian artery. The endoleak disappeared in the postoperative CT.

Vascular endothelial growth factor-C derived from CD11b+ cells induces therapeutic improvements in a murine model of hind limb ischemia.

OBJECTIVE: The use of bone marrow cells (BMCs) in therapeutic angiogenesis has been studied extensively. However, the critical paracrine effects of this treatment are still unclear. Therefore, we studied autotransfusable cells that produce vascular endothelial growth factor (VEGF), especially VEGF-C. METHODS: Male C57BL/6 mice with hind limb ischemia were administered intramuscular injections of phosphate-buffered saline as controls, or unsorted BMCs, sorted CD11b(+), or CD11b(-) cells from BMCs, and recombinant VEGF-C. To evaluate the treatments, perfusion was measured by laser Doppler scanning performed on days 0, 1, 3, 7, 14, 21, and 28. A functional assay was performed in parallel, with mice traversing an enclosed walkway. Capillary density was determined by directly counting vessels stained positive with von Willebrand factor at individual time points. Lymphangiogenesis was assessed by LYVE-1 positive cells. RESULTS: Postischemic recovery of hind limb perfusion significantly improved in BMC, CD11b(+), and VEGF-C treatment groups compared with the control groups, as assessed by laser Doppler scanning. On early operative days 1 and 3, the blood flow recovery ratio was higher in the CD11b(+)-treated group compared with BMC and VEGF-C treatment groups. In the functional assay, the VEGF-C group dramatically recovered compared with the control group. The capillary/myofiber ratio in the thigh muscle and number of LYVE-1 positive cells was higher in the CD11b(+) and VEGF-C groups than in controls. Furthermore, expression of VEGF-A, VEGF-C, and VEGF receptor messenger ribonucleic acid and protein was observed in CD11b(+) cells. CONCLUSIONS: The VEGF-C derived from CD11b(+) cells play a critical role in angiogenesis and lymphangiogenesis in a murine model of hind limb ischemia. Consequently, treatment with self-CD11b(+) cells accelerated recovery from ischemia and may be a promising therapeutic strategy for peripheral arterial disease patients.

Long-term prognosis of patients with Kawasaki disease complicated by giant coronary aneurysms: a single-institution experience.

BACKGROUND: Some patients with Kawasaki disease develop giant coronary aneurysms and coronary stenosis, leading to ischemic heart disease. The aim of this study was to determine the long-term prognosis of patients with Kawasaki disease with giant aneurysms. METHODS AND RESULTS: From our institutional database, 76 patients (57 men and 19 women) who developed giant aneurysms after January 1, 1972, were identified. Information on patient demographics, catheter and surgical interventions, and most recent status was collected from medical charts and patients' contacts. From these data, we calculated the survival rate and cumulative coronary intervention rate. The average age at onset was 2.9±2.9 years, and the median observational period was 19 years. During this period, 7 patients died and 1 patient underwent a heart transplantation, resulting in 95%, 88%, and 88% survival rates at 10, 20, and 30 years after the onset of KD, respectively. On the other hand, catheter and surgical coronary interventions (median, 1 intervention; range, 1 to 7 interventions) were performed to alleviate coronary ischemia in 46 patients (61%) at 1 month to 21 years (mode at 1 month) after onset, resulting in 28%, 43%, and 59% cumulative coronary intervention rates at 5, 15, and 25 years after onset, respectively. CONCLUSIONS: The long-term survival of patients with Kawasaki disease complicated by giant coronary aneurysms is moderately good with multiple catheter and surgical interventions. Further research should focus on the prevention of coronary vascular remodeling and on the indications for and effectiveness of percutaneous and surgical coronary interventions.

Safety and efficacy of an ultrashort-acting ß1-blocker on left ventricular dysfunction.

Landiolol hydrochloride, an ultrashort-acting ß1-selective blocker, is a highly regulated drug. This study evaluated the safety and efficacy of this drug for cases of coronary artery bypass grafting (CABG) with left ventricular dysfunction. Between September 2006 and August 2009, 32 patients with a left ventricular ejection fraction of <40% underwent CABG. Two groups of patients, a group administered landiolol hydrochloride and a control group not administered this drug, were compared. The administration of landiolol hydrochloride was initiated at 1 µg/kg per minute (γ) after cardiopulmonary bypass in on-pump cases and after completion of all the distal anastomoses in off-pump cases. We observed no significant differences between the groups with respect to preoperative patient background or incidences of complications, except for postoperative atrial fibrillation. The heart rate decreased significantly 30 minutes after landiolol hydrochloride administration, but no change was observed in arterial pressure. No change was observed in other parameters; the hemodynamics were stable. The occurrence of atrial fibrillation during the intensive care unit stay (during landiolol hydrochloride administration) was significantly lower in the administration group. The difference remained significant after multiple logistic regression analysis; landiolol hydrochloride was the sole inhibitory factor.

[Current strategy of surgical treatment for ischemic heart disease].

Coronary artery bypass grafting (CABG) surgery is the gold standard therapy for the complete revascularization of patients with multivessel coronary artery disease. Since off-pump CABG (OPCAB) began to be performed, to avoid any side effects from cardiopulmonary bypass, OPCAB is now performed in 66% of all isolated CABG in Japan, and this situation is markedly different from the procedures performed in North America and Europe. Furthermore, percutaneous coronary intervention (PCI) using drug eluting stents (DES) is now being increasingly performed for the treatment of patients with either left main trunk, diffuse or multivessel lesions. Under these circumstances, both the surgical treatment and indications for ischemic heart disease has also changed, and therefore what is asked of surgeons is how they can provide high quality treatment that maintains surgical quality. The strategy to be pursued by surgeons in the future is to perform treatment that is less invasive and provides maximum effects and it is believed that the following issues will become more important. (1) Using arterial grafts for various purposes to maintain high rates graft patency. (2) Successfully performing multivessel bypass procedures and achieving good complete revascularization rates. (3) Careful postoperative management and its complications.

Off-pump coronary artery bypass vs percutaneous coronary intervention. Therapeutic strategies for 3-vessel coronary artery disease: OPCAB vs PCI(PCI-Side).

Coronary artery bypass graft (CABG) surgery is still the best therapy for patients with multivessel and left main coronary artery disease. Recently, the introduction of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in these patients has improved the restenosis rate compared with bare metal stents. Furthermore, according to the results of the SYNTAX trial, no differences were found in the frequencies of mortality or myocardial infarction between CABG and PCI patients. PCI with DES is being increasingly performed for the treatment of patients with either left main trunk, diffuse, or multivessel lesions. In Japan, to avoid any side effects from cardiopulmonary bypass, off-pump coronary artery bypass (OPCAB) was performed in 66% of the total isolated CABG procedures in 2009, and is markedly different from the procedures performed in North America and Europe. However, the comparative effectiveness of PCI and OPCAB remains uncertain. In the present study, the current evidence from randomized trials, a meta-analysis and several observation studies are reviewed.

Efficacy of propafenone hydrochloride in preventing postoperative atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: Atrial fibrillation (AF) is one of the most common complications after coronary artery bypass grafting (CABG), and the incidence of postoperative AF (PAF) is estimated to range from 10% to 40%. PAF is a serious complication that is related to unstable hemodynamics, development of embolisms, patient discomfort, and increased medical costs associated with the prolongation of hospital stay. Sometimes, immediate attention is also necessary. In this study, we assessed the efficacy of treatment with the antiarrhythmic drug propafenone hydrochloride, which was administered in the early postoperative period, in preventing the development of PAF, and we attempted to identify risk factors for PAF. MATERIALS AND METHODS: The subjects were 78 patients who underwent isolated off-pump CABG between July 2007 and October 2008. We conducted the study by dividing the patients into 2 groups, a group of 26 patients who received propafenone hydrochloride (P group) and a control group of 52 patients who did not receive this drug (C group). The patients in the P group were given propafenone hydrochloride (150-450 mg/day orally) for 10 days, starting on the day after surgery, and were observed for the development of AF by means of continuous 12-lead electrocardiographic monitoring. Development of AF was defined as AF that lasted

Current Status of Off-Pump Coronary Artery Bypass.

PURPOSE: Off-pump coronary arterial bypass grafting (OPCAB) has become a common practice for coronary artery bypass grafting (CABG) in Japan, with approximately 65% CABG procedures currently being performed using OPCAB. However, it is unclear whether OPCAB is superior in terms of associated mortality, incidence of complications, graft patency rate, and long-term outcomes compared with conventional CABG (CCABG). METHODS: Literature consideration was performed, mainly based on observational studies involving large samples and randomized controlled trials (RCTs). RESULTS: Many RCTs indicated that the acute-phase and long-term mortality rates were comparable between CCABG and OPCAB or that OPCAB was inferior to CCABG. In contrast, many observational studies indicated that OPCAB was superior to CCABG. CONCLUSION: CABG is a delicate procedure, the outcomes of which vary in accordance with the patient's condition as well as the level of expertise of the associated institution and surgeon. In the future, we hope that reports will emerge with excellent results, including long-term results, from Japanese institutions experienced in performing OPCAB.

Randomized clinical trial of an elastomeric sealant for hemostasis in thoracic aortic surgery.

OBJECTIVES: This study aimed to demonstrate the efficacy and safety of a newly developed elastomeric sealant, which does not require any blood coagulation system to exert its effect, during thoracic aortic surgery. METHODS: This is a multicenter, randomized study conducted in six hospitals in Japan. A total of 81 patients undergoing replacement surgery of a thoracic aortic aneurysm using cardiopulmonary bypass were randomized with a ratio of 2-:1 for those patients designated to receive the sealant (Group S, 54 patients) or those without the usage of the sealant (Group C, 27 patients). The primary endpoints were bleeding from each anastomosis at two time points: (1) immediately before applying protamine and (2) 15 min after applying protamine. The patients were followed for 6 months. RESULTS: The number of anastomoses checked for bleeding was 196 in Group S and 117 in Group C. Before protamine sulfate administration, complete hemostasis was obtained in 155 anastomoses (79%) in Group S compared to 45 anastomoses (38%) in Group C (p < 0.001). Fifteen minutes after the administration of protamine sulfate infusion, bleeding stopped completely in 173 anastomoses (88%) in Group S and in 71 anastomoses (61%, p < 0.001) in Group C. Between the two groups, there were no marked differences in the patient background or in the incidence of major adverse events. CONCLUSIONS: The sealant is effective in achieving hemostasis, even under fully heparinized conditions. The novel sealant is safe and effective in thoracic aortic surgery, one of the most demanding surgical situations for hemostasis.

Endoscopic radial artery harvesting for coronary artery bypass grafting: the initial clinical experience and results of the first 50 patients.

BACKGROUND: The radial artery (RA) is a commonly used arterial conduit in coronary artery bypass grafting (CABG). Traditional open-vessel harvest often leads to postoperative wound complications and cosmetic problems. Endoscopic RA harvesting (ERAH) has been widely used to prevent these problems. The purpose of this study was to assess these problems and graft patency in the first 50 patients who underwent ERAH. METHODS: Between February 2006 and October 2007, 50 patients underwent ERAH with the VasoView system (Boston Scientific). These patients were compared with 50 patients who underwent the traditional open technique. RESULTS: The mean age was 62.8 years in both groups. All RAs were successfully harvested. No conversion was made from ERAH to the traditional open technique. The mean harvesting time (forearm ischemic time) was 27.4 + or - 6.5 minutes, and the mean length of the RA in the ERAH group was 18.5 cm. Neither wound complications, such as wound infection and skin necrosis, nor severe neurologic complications were recorded. The patency rate was 95.9% (95/99) in the ERAH group and 94% (94/100) in the open group. CONCLUSION: ERAH can be performed safely, and the early results are satisfactory. Endoscopic vessel harvesting is therefore recommended as the technique of choice for RA harvesting.

IgG4-positive plasma cells in inflammatory abdominal aortic aneurysm: the possibility of an aortic manifestation of IgG4-related sclerosing disease.

Inflammatory abdominal aortic aneurysm (IAA) is associated with autoimmune disease. However, the precise mechanism of IAA remains unclear. There is increasing evidence that IgG4 is involved in the autoimmune mechanism of various idiopathic sclerosing lesions, including sclerosing pancreatitis and retroperitoneal fibrosis. The present study investigated the hypothesis that the IgG4-related autoimmune reaction is involved in the formation of IAA. The study group consisted of 11 cases of IAA (69.2 +/- 8.59y) and 12 age-matched cases of atherosclerotic abdominal aortic aneurysm (AAA, 69.6 +/- 5.94y), which were used in the previous report. A clinicopathologic examination of these lesions was performed, including histology and immunohistochemistry, in relation to the involvement of IgG4-positive plasma cells in the formation of IAA. No difference in the incidence of risk factors for atherosclerosis was observed between the patients with IAA and AAA. Autoimmune diseases were diagnosed in 2 patients with IAA, including rheumatoid arthritis and polyarteritis nodosa. A patient with IAA had pulmonary fibrosis. In contrast, autoimmune diseases were absent in patients with AAA. However, there was no significant difference in the incidence of autoimmune diseases between the patients with IAA and AAA. Lymphocyte and plasma cell infiltration and fibrosis were significantly more intense and extensive in IAA than in AAA. In addition, lymph follicle formation and vasculitis of small veins and arteries were frequently found in the affected lesions of IAA. Immunohistochemically, IAA showed a significant increase in the number of infiltrating IgG4-positive plasma cells and the incidence of a disrupted follicular dendritic cell network in lymph follicles, in comparison with AAA. These findings suggest that IAA may be an aortic lesion reflecting the presence of IgG4-related sclerosing disease, and not a simple inflammatory aneurysm of the aorta.

Possible involvement of myofibroblast in the development of inflammatory aortic aneurysm.

To clarify the role of myofibroblasts in the development of inflammatory aortic aneurysm (IAA), 11 cases of IAA (69.2+/-8.59 years) were investigated immunohistochemically and were morphometrically compared with 12 age-matched cases of atherosclerotic abdominal aneurysm (AAA, 69.6+/-5.94 years). The positivity of mantle sign and CRP was significantly higher in the IAA group than in the AAA group. The wall of IAA (5.41+/-1.47 mm) was significantly thicker than that of AAA (2.68+/-0.71 mm). A significant increase in the expression of alpha-smooth muscle actin was found in adventitial fibroblasts of IAA compared to those of AAA. The cell density and MIB-1 index of adventitial myofibroblasts were significantly higher in IAA than in AAA (cell density: 1.69+/-0.51 vs. 1.09+/-0.4 x 10(3) cells/mm(2); MIB-1 index: 5.25+/-2.97% vs. 1.55+/-0.71%). IAA showed a significantly lower area ratio (MAR) of adventitial microvessels than did AAA (2.92+/-1.49% vs. 7.51+/-2.64%). However, there was no significant difference in microvessel density (MVD) between IAA and AAA (84.62+/-50.5 vs. 65.1+/-32.6 vessels/mm(2)). In some cases of IAA, adventitial myofibroblasts expressed hypoxia-inducible factor 1alpha in their cytoplasm or nuclei while it was not detected in AAA. These findings suggest that the development of IAA may be partly mediated by the proliferation of adventitial myofibroblasts, which might be related to tissue hypoxia.

Coronary artery bypass grafting in DES era.

Coronary artery bypass grafting (CABG) has played an important role in the treatment of ischemic heart disease. Recently, the introduction of a drug-eluting stent (DES) has decreased the incidence of restenosis after percutaneous intervention (PCI). PCI with a DES is being increasingly performed, whereas the number of patients for whom CABG has been indicated has decreased over the last few years in Japan and the United States. According to a report, the number of patients undergoing CABG will not decrease in the future due to its usefulness in the treatment of multi-vessel lesions. We have also reviewed how CABG should be improved. For this purpose, it may be important to carry out less invasive CABG by the off-pump method and to improve the long-term results obtained by CABG with an internal thoracic artery graft and complete revascularization. Hence, CABG may achieve better long-term results compared with PCI and continued future application of CABG.

Early outcome of a randomized comparison of off-pump and on-pump multiple arterial coronary revascularization.

BACKGROUND: Previous randomized comparisons of off-pump and on-pump coronary artery bypass grafting (CABG) have yielded controversial results about the cardiac and neurological events and graft patency. In addition, these randomized studies were composed of CABG with a few arterial grafts. We performed a prospective randomized controlled study to compare off-pump and on-pump CABG with multiple arterial grafts. METHODS AND RESULTS: Between July, 2002, and September, 2004, 167 consecutive unselected patients referred for elective primary CABG were randomly assigned to undergo multiple arterial off-pump CABG (n=81) or on-pump CABG (n=86). The clinical outcomes and S-100 protein, neuron-specific enolase, and maximum creatine kinase-MB levels were compared. Early graft patency was examined within 3 weeks after the operation by angiography. The number of grafts performed per patient (3.5+/-1.0 for off-pump CABG and 3.6+/-0.9 for on-pump CABG) and the number of arterial grafts performed per patient (3.3+/-1.0 for off-pump CABG and 3.4+/-0.9 for on-pump CABG) were similar. Completeness of revascularization (completed grafts/planned grafts) was 98% in both procedures. There were no hospital deaths in either group. The operation time was significantly (P<0.001) shorter in the off-pump group than in the on-pump group (267+/-60 minutes versus 307+/-59 minutes). The incidence of perioperative complications was similar. The frequency of no need for transfusion was higher in the off-pump group than in the on-pump group (80% versus 55%, P<0.001). The S-100 protein levels at the admission into the intensive care unit were significantly (P<0.001) lower in the off-pump group than in the on-pump group (0.20+/-0.11 ng/mL versus 0.34+/-0.22 ng/mL). The neuron-specific enolase levels at the intensive care unit admission were significantly (P<0.001) lower in the off-pump group than in the on-pump group (10.4+/-9.0 ng/mL versus 16.9+/-6.9 ng/mL). Maximum creatine kinase-MB levels were significantly (P=0.046) lower in the off-pump group than in the on-pump group (17.1+/-16.7 IU/L versus 21.5+/-10.6 IU/L). The overall early graft patency rate with or without stenosis was the same (98%) in both groups, but the rate without stenosis was slightly worse in the off-pump group (93%) than in the on-pump group (96%) (P=0.093). The stenosis-free patency rate in the right coronary area was significantly (P=0.028) worse in the off-pump CABG group (90%) than in the on-pump group (99%). CONCLUSIONS: Off-pump CABG with multiple arterial grafts was as safe as the conventional on-pump CABG, with similar completeness of revascularization and early graft patency.