Neoadjuvant Hyperthermia and Chemoradiotherapy for Borderline Resectable Pancreatic Cancer.

Pancreatic cancer(PC)is associated with poor prognosis and low resectability rates. Currently, only 15-20% of all patients are candidates for upfront surgery at the time of diagnosis, which offers the chance of long-term survival. In recent years, patients with borderline resectable PC(BR-PC)have been treated with surgery following neoadjuvant chemoradiotherapy or intensive multi-agent chemotherapy. In PC, which is therapy resistant due to its hypoxic microenvironment, hyperthermia may enhance the effect of chemo(radio)therapy. An 84-year-old man with fatty stool was diagnosed with pancreatic head cancer according to the result of contrast computed tomography(CT), which showed a 37 mm irregular low-density area at the pancreatic head infiltrating nearly half of the superior mesenteric artery(SMA)plexus. There were no findings of lymph node metastasis or distant metastasis. The pretreatment diagnosis was BR-PC, cT3, N0, M0, cStage Ⅱ A. The patient was treated with hyperthermia plus S-1 and radiotherapy. The size of the tumor had reduced from 37 mm to 15 mm after the neoadjuvant therapy, and the infiltration into the SMA plexus had also reduced. Therefore, the patient underwent subtotal stomach-preserving pancreaticoduodenectomy(SSPPD)concomitant resection of the PV, SMV, SV confluence. The histopathological findings were invasive ductal carcinoma with R0 radical resection. There has been no recurrence 18 months after the surgery. Based on the above-mentioned findings, hyperthermia and chemoradiotherapy can be an effective option of neoadjuvant treatment for BR-PC.

[Two Cases of Surgery Combined with Intraoperative Radiofrequency Ablation for Colorectal Cancer and Synchronous Liver Metastases].

The therapeutic management of simultaneous liver metastasis of colorectal cancer(SCRLM)remains controversial. Although hepatic metastasectomy is the first choice for resectable liver metastasis of colorectal cancer, radiofrequency ablation (RFA)is one of the least invasive application for patients who refuse more invasive treatment such as hepatectomy and longterm systemic chemotherapy or for whom such treatment is not suitable. We report 2 cases of SCRLM treated by surgery combined with intraoperative RFA and adjuvant chemotherapy, raising the possibility of local control in the liver for selected patients.

[A Case of Recurrent Gallbladder Carcinoma Treated with Resection and Hepatic Arterial Infusion].

A 69-year-old woman underwent extended cholecystectomy for gallbladder cancer[T2N0M0, fStage Ⅱ(UICC 7th edition)]. She was then administered adjuvant S-1 and was treated for drug-induced neutropenia. One year later, recurrent lesions were detected in liver S4 and S5. We treated the patient with hepatectomy and hepatic arterial infusion adjuvant chemotherapy by cisplatin, along with the systemic administration of gemcitabine for 10 months. The patient is now doing well without any sign of recurrence 29 months after the initial operation and 16 months after the secondary liver resection.

Structural valvular deterioration of Hancock standard valve in the mitral position 33 years after initial implantation.

A 77-year-old woman who had undergone mitral valve replacement (MVR) with a 29 mm Hancock standard (H-S) bioprosthesis (Model 242) and tricuspid annuloplasty (Kay's method) at the age of 44 years was admitted urgently with acute heart failure. Echocardiography showed severe transvalvular leakage of the prosthesis and moderate tricuspid regurgitation. The patient underwent reMVR with a 29 mm Carpentier-Edwards Perimount Magna Mitral bioprosthesis and tricuspid annuloplasty with a 30 mm MC3 ring. The explanted bioprosthesis showed mild calcification and a tear in the leaflet, dehisced commissures and pannus overgrowth. To our knowledge there are no reports describing H-S valves that were still functioning over 30 years after implantation. Herein, we report a case of reMVR in a patient with an H-S valve that had been implanted 33 years previously.

Aortic Stenosis in a Patient With Sjogren's Syndrome.

Sjogren's syndrome (SS) is an autoimmune disease characterized by dryness of the mouth and the eyes. Systemic involvement in SS is well known, however, obvious cardiac manifestations, particularly significant valve disorders, are extremely rare and only three cases of significant valve disease associated with SS that required surgical intervention have been previously described. We report a case of aortic stenosis (AS) associated with SS in an elderly patient. The diagnosis of primary SS had been made based on clinical features, positive ocular signs, and positive serologic findings. Echocardiography showed severe calcification, elevated mean pressure gradient (57 mmHg), and a small orifice area (0.45 cm(2)) of the aortic valve. At surgery, severe calcification of the aortic cusps and the annulus was the mechanism of AS, and the aortic valve was replaced with a bioprosthetic valve. Valve pathology showed nodular calcification and hyaline degeneration, but lymphocyte infiltration was not evident. The etiologic relation of SS to the valve lesions is not clear pathologically in this case, however, chronic inflammation related to immunologic reactions in SS could have some effect on exacerbation for degeneration of the valve tissue.

Sutureless repair for left ventricular free wall rupture after acute myocardial infarction.

We report three cases of left ventricular free wall rupture (LVFWR) after acute myocardial infarction, which were repaired using a sutureless technique without cardiopulmonary bypass. At operation, a sheet of fibrin tissue-adhesive collagen fleece (TachoComb) was secured to the hematoma surrounding the tear and the infarcted area under compression by the surgeon's fingers. After complete hemostasis, several sheets of an absorbable gelatin sponge (Gelfoam) were glued onto the collagen fleece in layers. Intra-aortic balloon pumping was electively performed. Concomitant coronary artery bypass grafting was not carried out. All patients survived the operation but recurrence of the rupture occurred on postoperative day 10 in one patient and an LV aneurysm was found four months after repair in another patient. The sutureless technique may be a simple and fast option for treatment of an oozing type LVFWR; however, careful follow-up is mandatory.

Structural valve deterioration in a starr-edwards mitral caged-disk valve prosthesis.

BACKGROUND: The durability of the Starr-Edwards (SE) mitral caged-disk valve, model 6520, is not clearly known, and structural valve deterioration in the SE disk valve is very rare. METHODS AND RESULTS: Replacement of the SE mitral disk valve was performed in 7 patients 23-40 years after implantation. Macroscopic examination of the removed disk valves showed no structural abnormalities in 3 patients, in whom the disk valves were removed at <26 years after implantation. Localized disk wear was found at the sites where the disk abutted the struts of the cage, in disk valves excised >36 years after implantation in 4 patients. Disk fracture, a longitudinal split in the disk along its circumference at the site of incorporation of the titanium ring, was detected in the valves removed 36 and 40 years after implantation, respectively, and many cracks were also observed on the outflow aspect of the disk removed 40 years after implantation. CONCLUSIONS: Disk fracture and localized disk wear were found in the SE mitral disk valves implanted >36 years previously. The present results suggest that SE mitral caged-disk valves implanted >20 years previously should be carefully followed up, and that those implanted >30 years previously should be electively replaced with modern prosthetic valves

Right Coronary Artery with an Intramural and Interarterial Course as a Unique Cause of Myocardial Ischemia: The Unroofing Method Might Still Be the Best Solution.

A 39-year-old man was admitted because of cardiac arrest. Emergent coronary angiography revealed a preserved coronary blood flow; however, multiple-row detector computed tomography (MDCT) revealed that the proximal right coronary artery (RCA) was running inside the aortic wall, creating proximal stenosis without atherosclerotic changes. Surgical intervention with unroofing was performed; however, postoperative stenosis of the proximal RCA required additional coronary artery bypass grafting (CABG). Intraoperative findings during CABG did not reveal hematoma or coronary dissection. However, MDCT one year after CABG depicted improvement of the RCA and graft stenoses, suggesting that the post-unroof stenosis may have been caused by an inflammatory reaction after surgical intervention.

[Issues and indications for off-pump coronary artery bypass grafting].

We have evaluated the usefulness of off-pump coronary artery bypass grafting (CABG)[OPCAB]. The subjects were 153 patients who underwent isolated CABG between May 2005 and May 2009. They were divided into 2 groups( on-pump/arrest;ON group:76 subjects vs OPCAB;OFF group:77 subjects). The concomitant conditions, the number of bypasses, the postoperative outcome and the early graft patency rate were compared between the 2 groups. The mean age and the incidence of carotid artery lesions were significantly higher in the OFF group. The number of bypasses was significantly smaller in the OFF group. The postoperative intubation time and the length of postoperative hospitalization were significantly shorter in the OFF group. Concerning major postoperative complications, mediastinitis, cerebral infarction or bleeding was not observed in the OFF group. There was no hospital death in the OFF group. The early graft patency rate with saphenous vein graft (SVG) was significantly lower in the OFF group. Early stage extubation was achieved by the introduction of OPCAB. In some occasions, however, the target site could not be reached with OPCAB, and furthermore, the quality of anastomosis was poor. In order to achieve complete revascularization, therefore, on-pump/arrest surgery should be considered in some cases.

A case report of atrial fibrillation in a patient with heparin resistance associated with an antithrombin III deficiency successfully treated by radiofrequency catheter ablation using a direct thrombin inhibitor.

BACKGROUND: Pulmonary vein antrum isolation has proven to be a useful strategy for radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) worldwide. Anticoagulation therapies are necessary to avoid thromboembolic events before, during, and after RFCA of AF. During the RFCA procedure for AF, it is recommended that the activated coagulation time be maintained between 300 s and 400 s using heparin as an anticoagulation therapy. CASE SUMMARY: An 81-year-old man with symptomatic and drug-refractory paroxysmal AF underwent RFCA. We found that he had a severe heparin resistance during the RFCA procedure, and heparin had little effect on him. Thus, a direct thrombin inhibitor, Argatroban Hydrate®, was used instead of heparin for anticoagulation therapy during the procedure. Finally, the AF was successfully treated by RFCA without any complications. With a post-procedural inspection, we found that he had a Type-1 antithrombin III (AT-III) deficiency. DISCUSSION: Atrial fibrillation is the most common clinical arrhythmia and is associated with significant clinical morbidity and increased mortality. An AT-III deficiency is a well-known autosomal dominant hereditary disease and congenital blood coagulation abnormality occurring in about 1:500-5000 live births that may sometimes cause thrombophilia. Thus, the physicians may occasionally come across patients with an AT-III deficiency in real-world clinical practice, even though they have no history of thrombophilia. Argatroban Hydrate® may be effective and feasible for anticoagulation therapy during the RFCA procedure of AF in patients with heparin resistance such as in this present case.

Simultaneous laparoscopic total extraperitoneal inguinal hernia repair and laparoscopic appendectomy for Amyand's hernia: a case report.

BACKGROUND: An Amyand's hernia is defined by the presence of a vermiform appendix within an inguinal hernia sac. Most of these cases are not diagnosed preoperatively and the surgical approach is dependent on the type present and associated intraoperative findings. We present a case of a preoperatively diagnosed Amyand's hernia in a man who underwent treatment by simultaneous laparoscopic totally extraperitoneal repair and laparoscopic appendectomy. CASE PRESENTATION: We encountered the case of a 76-year-old Japanese man with a right inguinal pain. Ultrasound and computed tomography confirmed his vermiform appendix herniated into the right inguinal canal. We managed a simultaneous laparoscopic total extraperitoneal inguinal hernia repair with mesh and laparoscopic appendectomy. He was discharged without any postoperative morbidity. CONCLUSIONS: We recommend laparoscopic appendectomy and totally extraperitoneal hernia repair with mesh after laparoscopic reduction for Amyand's hernia.

Radiofrequency catheter ablation of premature ventricular contractions from near the His-bundle.

OBJECTIVE: This study aimed to investigate the effects of radiofrequency catheter ablation (RFCA) and clinical and electrophysiological characteristics in symptomatic patients with premature ventricular contractions (PVCs) from near the His-bundle (His-PVCs). METHODS: The patient characteristics, prevalence of complications with any life style related disease (ALSRD) including hypertension, dyslipidemia, or diabetes mellitus, and/or cardiovascular disease (CVD) including coronary artery disease, cerebrovascular disease, renal dysfunction, or cardiomyopathy, clinical status, frequency of PVCs evaluated by 24hour Holter monitoring, echocardiography including the left ventricular diastolic dysfunction (LVDD) parameters, and electrophysiological findings were evaluated in 14 consecutive symptomatic patients with His-PVCs. RESULTS: The prevalence of males, being elderly and/or slightly obese, current and/or history of smoking, ALSRD or CVD related complications, and LVDD probably resulting from ALSRD and/or CVD complications were higher in patients with His-PVCs. RFCA of His-PVCs steadily decreased the PVC frequency and improved the systolic function, LV dilation, and clinical status, but not the LVDD. There was a significant relationship between the accordance rate of the QRS polarity between sinus rhythm and His-PVCs and the distance between the successful ablation site and His-bundle. CONCLUSION: The analysis of the QRS duration and accordance rate of the QRS polarity between sinus rhythm and His-PVCs before the RFCA may help to determine the distance between the origin of the PVCs and His-bundle. Further, the appropriate ablation catheter may be selected during the RFCA procedure. Finally, RFCA may be one of the most effective, feasible, and safest therapies for symptomatic patients with His-PVCs.

Paroxysmal Atrial Fibrillation in Patients Successfully Treated by Radiofrequency Catheter Ablation with Severely Compression, Lateral Displacement, and Clockwise Rotation of Their Hearts due to Severe Pectus Excavatum.

Two cases with severe pectus excavatum and symptomatic atrial fibrillation (AF) underwent radiofrequency catheter ablation (RFCA). Their chest X-ray and computed tomography (CT) findings revealed lateral displacement and clockwise rotation of their hearts, and severe right atrial and mild right ventricular compression against the sternum, but no left atrium compression against the spinal column. The procedure was therefore carefully performed under guidance with CT, intra-cardiac echography, atriography, and a three-dimensions mapping system. Finally, the AF was successfully treated by RFCA without any complications. These findings underscore the importance of understanding cases of abnormal anatomy and carefully designing a strategy before performing any procedure.

A case of paroxysmal atrial fibrillation in a patient successfully treated by radiofrequency catheter ablation with a severely right-sided dislocation of the heart after a total right lung excision.

A 72-year-old woman with symptomatic and drug-refractory paroxysmal atrial fibrillation (AF) underwent radiofrequency catheter ablation (RFCA). She had a history of a total right lung excision. Her chest X-ray and computed tomography (CT) revealed a severely sight-sided dislocation of the heart. Thus, the procedure was carefully performed under guidance of a CT, intracardiac echogram, atriography, and 3D mapping system. Finally, the AF was successfully treated by RFCA without any complications.

Inappropriate Sinus Tachycardia Diagnosed and Treated as Depression Successfully Treated by Radiofrequency Catheter Ablation.

We experienced a man in his 20s with inappropriate sinus tachycardia (IST) initially diagnosed and treated as depression who was steadily treated with radiofrequency catheter ablation (RFCA) using an EnSite™ system. The patient has remained well without any symptoms or medications, including antidepressants, for two years since the RFCA. To avoid missing IST and treating it as an emotional problem and/or mental illness such as depression, physicians - including cardiologists - should be aware of these conditions when examining patients with multiple and incapacitating complaints including palpitations and general fatigue and/or tachycardia, especially characterized by an elevated resting heart rate or a disproportionate increase in the heart rate with minimal exertion.

A case of premature ventricular complexes/ventricular tachycardia from the left ventricular outflow tract successfully ablated from the distal great cardiac vein.

We experienced a 41-year-old male with premature ventricular complexes/ventricular tachycardia from the left coronary cusp and distal great cardiac vein of the left ventricular outflow tract successfully treated by radiofrequency catheter ablation utilizing a 3D mapping system (EnSiteNavX/Velocity™ Cardiac Mapping System, St. Jude Medical, St. Paul, MN, USA) without any complications. .

Clinical benefits of deep sedation with a supraglottic airway while monitoring the bispectral index during catheter ablation of atrial fibrillation.

BACKGROUND: Pulmonary vein antrum isolation (PVAI) under sedation has proven to be a useful strategy for catheter ablation of atrial fibrillation (AF). METHODS: To evaluate the clinical benefits of respiratory management using supraglottic airways (SGAs) under deep sedation while monitoring the bispectral (BIS) index during the PVAI and the durations from admission to the catheterization room to starting the radiofrequency energy delivery (Time α), and from starting the radiofrequency energy delivery to completion of the PVAI (Time ß), X-ray time, frequency of dislocations of the three-dimensional maps (D3DM), procedure-related complications, and proportion of an AF-free rate 15 months after the PVAI (PAFFR) in patients who received deep sedation without SGAs (Group A: n=48) and those with SGAs (Group B: n=51) were evaluated. RESULTS: There were no significant differences in patient characteristics, Time α (77±3 versus 78±2 min; p=0.816), complications of cardiac tamponade (2% versus 2%; p=0.966), or PAFFR (81% versus 88%; p=0.313) between the two groups. However, the Time ß (84±4 versus 67±3; p=0.001), X-ray time (53±2 versus 34±2; p<0.001), and minor complications of nasal bleeding (25% versus 0%; p=0.001) were significantly shorter and lower in Group B than in Group A, in accordance with a reduction in the hypoxia (15% versus 0%; p=0.007) and D3DM (31% versus 8%; p=0.003). CONCLUSIONS: These results may demonstrate the clinical benefits of deep sedation with SGAs while monitoring the BIS index without any hypoxia during PVAI in patients with AF.

Aortic valve replacement after esophagectomy with substernal gastric tube reconstruction.

A 67-year-old woman with a history of esophagectomy with substernal gastric tube (GT) reconstruction and left lower lobectomy required aortic valve replacement (AVR) for aortic valve regurgitation and stenosis. Through a median sternotomy (MS) with cardiopulmonary bypass (CPB), we performed AVR without injury to the GT. Careful peeling of the GT and detailed information of the operative field by multidetector-row computed tomography (MDCT) scan enabled us to carry out the operation safely in the usual operative view.

A case of fulminant myocarditis treated with very long-term support by cardiopulmonary support system.

Fulminant myocarditis (FM) sometimes causes severe left ventricular dysfunction and lethal arrhythmias leading to cardiogenic shock and critical conditions. Thus, mechanical circulation support with intra-aortic balloon pumping and/or a cardiopulmonary support system (CPS) is sometimes needed to save lives. The special recommended therapies for FM for that classified as class I (evidence level C) in the guidelines of the Japanese Circulation Society are intra-aortic balloon pumping, CPS, percutaneous cardiac pacing, and a left ventricular assist device (LVAD), and they are well established in evidence-based medicine. We experienced a case of FM that we were able to save by long-term stable CPS support. Because, unfortunately, the LVAD was not commercially available in Japan at that time, intensive treatments including CPS were continued in our hospital. Finally, a good course of the illness was achieved without any adverse complications. Thus, these intensive treatments in the present case may be one of the optional effective strategies for FM, especially in hospitals and/or countries where the LVAD is not (commercially) available, and when an LVAD may not be suitable because of complications associated with infectious disease. .

Silent myocardial ischemia in asymptomatic patients with type 2 diabetes mellitus without previous histories of cardiovascular disease.

BACKGROUND: The number of patients with type 2 diabetes mellitus (T2DM) continues to increase all over the world. Cardiovascular disease (CVD), especially coronary artery disease (CAD), is a major cause of the morbidity and mortality in patients with T2DM. The prognosis of patients with silent myocardial ischemia (SMI) is worse than that in those without. METHODS AND RESULTS: Thus, to assess how many patients with SMI existed among those patients, CVD screening tests were performed in 128 asymptomatic patients with T2DM without previous histories of CVD. SMI could be detected in 24 patients (19%) by exercise stress tests and/or the coronary fractional flow reserve. Their 12-lead electrocardiogram and cardiac ultrasonography were both normal. Compared to those without SMI, those with had a statistically significant longer history of T2DM (17±1 versus 11±1years, p=0.006), and the co-existence of a family history of CVD (42% versus 21%, p=0.037). Furthermore, these factors were demonstrated as independent risk factors of SMI by a multivariate analysis (Odds ratio 1.060 and 4.000, respectively), and in accordance with the disease duration of T2DM, the prevalence of patients with SMI has been increasing (p=0.019). CONCLUSIONS: Physicians should be aware of these conditions when examining patients with T2DM, especially with a family history of CVD and/or long disease duration (>11years) of T2DM, even though they have no symptoms, previous histories of CVDs, and/or abnormal findings on the 12-lead electrocardiogram and cardiac ultrasonography. This may be an effective, safe, and attractive diagnostic strategy for those asymptomatic patients with T2DM.