[Operation for the Shaggy Aorta Syndrome].

Although mortality and complication rates of cardiovascular surgery have been reduced, shaggy aorta, which is defined as an extensive severe atherosclerosis of the thoracic and abdominal aorta, is considered a risk factor for perioperative mortality and complications. The shaggy aorta often leads a poor prognosis, and a very high hospital mortality rate when embolization occurs in multiple organs. Therefore, it is important to prevent embolism through detailed evaluation of the disease with preoperative contrast-enhanced computed tomography (CT) scan and intraoperative transesophageal echocardiogram, appropriate individualized treatment decisions, and careful surgical manipulation.

[Operation for Aortic Regurgitation after Replacement of Ascending Aorta].

It is not uncommon for aortic regurgitation to occur after ascending aortic replacement. There are various causes of the aortic valve insufficiency after ascending aorta replacement. Among them, most common is a reoperation after open repair of Stanford type A acute aortic dissection. Although it is becoming safer to perform reoperative cardiac surgery, the risks of operative mortality and morbidity is still higher than those of non-reoperative cardiac surgeries. In order to improve the mortality and morbidity rate, we should select the best strategies with a thorough preoperative evaluation. Moreover, a careful observation after the operation is required to find the complications, especially the patients who have the risk of aortic valve insufficiency.

[One-stage Radical Surgery for Aortoesophageal Fistula after Graft Replacement of Descending Aorta].

A 31-year-old woman was referred to our institution because of aortoesophageal fistula (AEF) six months after the descending aortic replacement for acute aortic dissection. We operated one-stage repair of the AEF. Thoracoscopic esophagectomy was firstly performed in prone position from right thoracic cavity, and then the esophagus was reconstructed with gastric conduit via posterior mediastinal route with omental flap. Secondly, graft replacement of the descending aorta using lateral oblique straight incision was performed and the graft was covered with omental flap simultaneously. The postoperative course was uneventful, and she started oral intake on the 13th day after surgery. Although the one-stage surgery for the AEF is highly invasive, it could be a good option for selected cases.

[Mitral Valve Plasty in a Patient with Multiple Metal Allergy;Report of a Case].

A 76-year-old woman was admitted to our hospital complaining of dyspnea on effort. Echocardiography showed severe mitral regurgitation. Her medical history indicated that she was allergic to metal, and skin patch tests were positive for nickel, cobalt, platinum, manganese, iridium, chromium, and zinc. Valvuloplasty involved triangular resection of P2 and mitral valve annuloplasty with a metal-free, 29 mm Tailor Flexible Ring. The sternum was closed using polyester non-absorbable sutures instead of surgical steel wire. Her postoperative course was uneventful and she was discharged on postoperative day 21. Nine months later, she is well and free of allergic symptoms.

[Abdominal Apoplexy after Mitral Valve Replacement Due to Infective Endocarditis;Report of a Case].

A 52-year-old woman with mitral valve insufficiency and congestive heart failure due to infective endocarditis was treated by mitral valve replacement with a mechanical valve. Warfarin was started on postoperative day (POD) 3, but sudden onset of anemia with left abdominal pain presented on POD 8. Abdominal apoplexy was diagnosed by computed tomography (CT) and ultrasonographic imaging, but active bleeding was not evident. She was hemodynamically stable and her prothrombin time-international normalized ratio(PT-INR) at that time was 1.70 (compared with 2.56 on POD 7). To avoid repeated bleeding, PT-INR was controlled at around 1.5. Other complications did not arise, and thereafter her postoperative course was favorable.

A therapeutic angiogenesis of sustained release of basic fibroblast growth factor using biodegradable gelatin hydrogel sheets in a canine chronic myocardial infarction model.

This study investigated the safety and efficacy of a sustained release of basic fibroblast growth factor (bFGF) with biodegradable gelatin hydrogel sheets as therapeutic angiogenesis in canine chronic myocardial infarction (MI) models. Canine chronic MI model was induced by ligating the left anterior descending coronary artery and its diagonal branches. At 4 week post-induction, we applied either saline (Control group, n = 5) or 200 µg of bFGF (Treatment group, n = 6) soaked gelatin hydrogel sheets on the ischemic area of the left ventricular (LV) wall. At 6 weeks after the procedure, we evaluated the efficacy by echocardiography and immunohistochemical study. There were no procedure-related adverse events or deaths. The serum bFGF level was under detectable levels in all animals at any sampling points. In terms of efficacy, echocardiographic evaluation demonstrated that fractional shortening was significantly improved in the treatment group. In addition, immunohistochemical study showed that the capillary density in the border zone of the MI area, as well as the MI area, significantly increased in the treatment group. Therapeutic angiogenesis by bFGF using biodegradable gelatin hydrogel sheets was safe, increased the capillary density, and improved LV function in canine chronic MI models.

[Effects of High-frequency Jet Ventilation on Respiratory Failure after Total Arch Replacement Due to Acute Aortic Dissection with Morbid Obesity;Report of a Case].

A 55-year-old morbidly obese woman [body mass index (BMI) 51.2] developed acute type A aortic dissection, and she also presented with significant hypoxemia and hypercapnia. She underwent a successful emergency total arch replacement, but severe hypoxemia persisted and Pao2/Fio2 lowered to 71.9 mmHg. We therefore applied high frequency jet ventilation (HFJV), which soon improved the hypoxemia without hemodynamic compromise. HFJV was discontinued three days later, when her Pao2/Fio2 improved to 170.0 mmHg. Weaning from the respirator was initiated on postoperative day 13. The patient was extubated on postoperative day 19 and was discharged on postoperative day 74 free from disabilities. HFJV may be effective for severe hypoxemia after cardiovascular surgery.

Safety and efficacy of sustained release of basic fibroblast growth factor using gelatin hydrogel in patients with critical limb ischemia.

As a form of therapeutic angiogenesis, we sought to investigate the safety and efficacy of a sustained-release system of basic fibroblast growth factor (bFGF) using biodegradable gelatin hydrogel in patients with critical limb ischemia (CLI). We conducted a phase I-IIa study that analyzed 10 CLI patients following a 200-µg intramuscular injection of bFGF-incorporated gelatin hydrogel microspheres into the ischemic limb. Primary endpoints were safety and transcutaneous oxygen pressure (TcO2) at 4 and 24 weeks after treatment. During the follow-up, there was no death or serious procedure-related adverse event. After 24 weeks, TcO2 (28.4 ± 8.4 vs. 46.2 ± 13.0 mmHg for pretreatment vs after 24 weeks, p < 0.01) showed significant improvement. Regarding secondary endpoints, the distance walked in 6 min (255 ± 105 vs. 318 ± 127 m, p = 0.02), the Rutherford classification (4.4 ± 0.5 vs. 3.1 ± 1.4, p = 0.02), the rest pain scale (1.7 ± 1.0 vs. 1.2 ± 1.3, p = 0.03), and the cyanotic scale (2.0 ± 1.1 vs. 0.9 ± 0.9, p < 0.01) also showed improvement. The blood levels of bFGF were within the normal range in all patients. A subanalysis of patients with arteriosclerosis obliterans (n = 7) or thromboangiitis obliterans (Buerger's disease) (n = 3) revealed that TcO2 had significantly improved in both subgroups. TcO2 did not differ between patients with or without chronic kidney disease. The sustained release of bFGF from biodegradable gelatin hydrogel may offer a safe and effective form of angiogenesis for patients with CLI.

[Neuroendovascular Treatment for Cerebral Embolism in a Patient just after Aortic Valve Replacement；Report of a Case].

A 67-year-old woman suffered from severe aortic stenosis and atrial fibrillation, and underwent aortic valve replacement with a St. Jude Medical Regent 23-mm valve and pulmonary vein isolation using an AtriCure Isolator Synergy.At 6 days after the operation, she experienced sudden onset of atrial fibrillation, left side paralysis, and dysarthria. Right internal carotid artery embolism was diagnosed via magnetic resonance imaging, and we promptly performed neuroendovascular therapy with a Solitaire FR. Neuroendovascular treatment succeeded, and her neurological function was restored to near-normal. Her post-treatment course was uneventful, and she is currently well without neurological dysfunction.

En bloc excision of giant polycystic liver with hepatic cava and its auto-transplant caval reconstruction as a safe surgical procedure for liver transplantation.

Safely excising a giant liver while leaving the hepatic inferior vena cava intact is difficult. Hata et al. present images and videos describing their novel technique consisting of total hepatectomy including the hepatic cava; extracorporeal retrieval; and auto-transplant inferior vena cava reconstruction, for an extremely enlarged polycystic liver weighing 24 kg.

Surgical management of a giant atrial septal aneurysm.

We experienced a very rare case of surgical management of a giant atrial septal aneurysm. It is an interesting case and is supported by preoperative, intraoperative, and pathology images.

Coronary artery bypass grafting for an octogenarian with R II-B type with isolated single coronary artery.

We experienced a very rare case of isolated single coronary artery, in which the left main coronary artery passes between the aorta and pulmonary artery. It is the most potentially serious among the coronary artery anomalies, because it has the risk of myocardial infarction and sudden death in young ages.

Transcutaneous oxygen pressure as a surrogate index of lower limb amputation.

INTRODUCTION: A large number of clinical trials of therapeutic angiogenesis in patients with critical limb ischemia have been conducted in recent years. However, limb amputation, which is used as a primary endpoint in such studies, is not often required in Japan, which can make it difficult to carry out related clinical trials. Transcutaneous oxygen pressure (TcPO2) is widely used to evaluate the severity of limb ischemia, to decide the level of amputation, and to predict wound healing after limb amputation. The aim of the present study was to elucidate whether TcPO2 can be a surrogate index of limb ischemia, and to define an appropriate cutoff value for wound healing after limb amputation using meta-analysis. EVIDENCE ACQUISITION: A computer search was performed to identify studies describing the association between TcPO2 and limb ischemic events. From these, studies focused on wound healing after limb amputation were combined and analyzed. EVIDENCE SYNTHESIS: Eleven studies were identified for inclusion in this analysis. The analysis demonstrated that TcPO2 20 mmHg was a valid cutoff value for limb amputation and TcPO2 30 mmHg would be an appropriate value for wound healing after limb amputation. CONCLUSIONS: TcPO2 of 20 and 30 mmHg were considered appropriate cutoff values for limb amputation and wound healing after amputation, respectively.

Effect of microRNA-145 to prevent vein graft disease in rabbits by regulation of smooth muscle cell phenotype.

OBJECTIVE: Because microRNA-145 (miR-145) is a specific mediator in the regulation of the proliferation and differentiation of smooth muscle cells, we investigated the effect of miR-145 on the intimal hyperplasia in the rabbit model of vein graft disease using electroporation-mediated gene transfer. METHODS: The right jugular vein of male Japanese white rabbits was harvested and transduced with miR-145-encoding plasmids using an electroporator and then interposed in the carotid artery. At 2 or 4 weeks postoperatively, the venous graft was explanted, and the intimal thickness and intima/media area ratio were evaluated. Furthermore, 3 days after implantation, the myocardin and serum response factors were measured using real-time polymerase chain reaction. At 2 weeks after implantation, immunohistochemical investigations using mature smooth muscle markers, myosin heavy chain smooth muscle-1 and -2, and proliferation marker Ki-67 were performed. RESULTS: MiR-145 transduction significantly reduced the neointimal thickness at both 2 and 4 weeks (2 weeks, 52.1 ± 15.7 vs 113.2 ± 26.9 µm, P < .05, n = 6; 4 weeks, 42.4 ± 4.8 vs 136.5 ± 38.3 µm, P < .05, n = 8), and it also significantly reduced the intima/media area ratio at 4 weeks (0.22 ± 0.04 vs 1.13 ± 0.23, P < .01, n = 8). Additionally, it upregulated the mRNA expression level of myocardin compared with that in the grafts that did not receive gene transfer. Smooth muscle-2 and Ki-67 expression revealed that miR-145 transduced grafts contained more smooth muscle-2-positive mature smooth muscle cells and fewer Ki-67-positive proliferating cells. CONCLUSIONS: Nonviral transduction of miR-145 into the bypass graft could be a novel option for preventing intimal hyperplasia in vein graft disease.