Midterm Results of Thoracic Endovascular Aortic Repair with Reentry Closure for Chronic Type B Aortic Dissection with Aneurysmal Dilatation.

Objectives: This study aims to discuss the midterm results of thoracic endovascular aortic repair (TEVAR) with reentry closure for chronic type B aortic dissection (CTBAD). Materials and Methods: This retrospective study analyzed 13 patients with CTBAD who underwent TEVAR with reentry closure between July 2014 and December 2020. We evaluated the false lumen (FL) cross-sectional area using computed tomography images of the descending aorta at the level of the bronchial bifurcation, Valsalva sinus, celiac artery, and infrarenal abdominal aorta pre- and postoperation. The study endpoints were technical and clinical success rates, freedom from additional aortic reintervention or surgery, and survival. Results: Technical success was obtained in 12 patients (92.3%) with no hospital mortality and neurological complications. The postoperative observation period was 49.2±21.5 months. The clinical success rate was 76.9% (10 cases), and a postoperative reduction of the FL cross-sectional area was obtained in 53.8% of patients. The 5-year overall survival rate was 64.8% with no aortic-related deaths while the 5-year freedom from additional aortic surgery rate was 66.7%. Conclusions: TEVAR with reentry closure suggests preventing FL dilatation or rupture in CTBAD, but the revision of our devices and further research with more patients and longer follow-up periods are required.

Longterm Followup of a Pediatric Patient with Congenital Abdominal Aortic Aneurysm with Coarctation.

Congenital abdominal aortic aneurysm (AAA) with coarctation has been considered an extremely rare condition. In this study, we present a 3-year-old boy, who was diagnosed by chance with congenital AAA at first operation. We replaced the AAA+coarctation with a 6-mm polytetrafluoroethylene (PTFE) graft. Histological examination of the aortic wall revealed no particular abnormalities. Collateral vessels were noted to develop over 14 years of followup. Good blood flow to both lower limbs and no intermittent claudication were observed. After growth, at the age 17, he underwent extra-anatomical bypass using a 12-mm PTFE graft. This is the first report of successful treatment of congenital AAA+coarctation with longterm followup.

Emergent Transcatheter Arterial Embolization via a Transpopliteal Approach for Internal Iliac Artery Injury during Lumbar Disk Surgery in the Prone Position.

This report describes a successful case of transcatheter arterial embolization for a critical vascular injury during lumbar disk surgery that resulted in a large retroperitoneal hematoma in a 72-year-old woman. A 4-Fr long sheath was inserted via the right popliteal artery in the prone position. Pelvic angiography revealed a pseudoaneurysm in the right internal iliac artery, which was managed with coil embolization. The patient underwent laparotomy because of abdominal compartment syndrome and was discharged in good condition after rehabilitation. The transpopliteal endovascular approach in the prone position may thus provide the best chance to treat this rare but critical condition.

Aberrant Glycosylation of Lumican in Aortic Valve Stenosis Revealed by Proteomic Analysis.

To identify proteins related to the pathophysiology of aortic valve stenosis (AS), we investigated the protein profiles of AS aortic valves. Specifically, proteins were extracted from a thickened and calcified area (AS-C) and an apparently non-thickened and non-calcified area (AS-N) in an identical aortic valve leaflet in each of 6 AS patients. The proteins were then separated by 2-dimensional gel electrophoresis (2DE). Protein spots detected by 2DE were compared between the AS-C and AS-N samples. Protein spots of interest were subjected to protein identification by mass spectrometry.In total, 670 protein spots were detected by 2DE, 28 of which showed more than 1.5-fold different intensity (P < 0.05) between the AS-C and AS-N samples. Proteins were identified in 17 out of the 28 spots. Fibrinogen and lumican were identified in 9 and 3 spots, respectively. Intensity of these 12 spots was lower in the AS-C samples than in the AS-N samples. In the 1D-Western blot analysis, 4 lumican bands (80 kDa, 75 kDa, 65 kDa, and 53 kDa) were detected, of which 2 bands with 80 kDa and 75 kDa showed lower intensity in the AS-C samples than in the AS-N samples. When de-glycosylated protein samples were used in the 1D-Western blot, only a single lumican band with ~40 kDa was detected, indicating that lumican was variously glycosylated and that highly glycosylated lumican molecules were decreased in AS-C.Collectively, insufficient glycosylation of lumican in the thickened and calcified areas of AS aortic valves may be involved in the pathophysiology of AS.

[Right ventricular rupture due to blunt trauma diagnosed by MDCT; report of a case].

The survival rate of cardiac rupture due to blunt trauma is generally low. We experienced a case with right ventricular rupture due to blunt trauma. The patient was a 49-year-old man who was crushed in a traffic accident and transported to a local hospital in a shock state. He was diagnosed with cardiac tamponade due to cardiac rupture, and for pericardial drainage was immediately performed. He was then transferred to our hospital for emergency surgery. His hemodynamics was stable, and he was diagnosed with right ventricular rupture by multi-detector row computed tomography (MDCT). The operation was performed successfully without cardiopulmonary bypass, and his postoperative course was uneventful. MDCT is useful for detecting the rupture site of the heart.

[Acute abdominal aortic occlusion in a patient with a giant thrombus in the left atrium and mitral stenosis; report of a case].

The patient was a 69-year-old male who had had percutaneous transvenous mitral commissurotomy (PTMC) 15 years ago, and had stopped taking warfarin after PTMC. He was transferred to our emergency room( ER) because of sudden severe pain in his both lower legs. We recognized pulselessness in his both femoral arteries, and pallor, paresthesia and poikilothermia in his lower extremities. Electorocardiogram(ECG) showed arterial fibrillation, and computed tomography( CT) showed occlusion of the abdominal aorta just below inferior mesenteric artery( IMA) and both common iliac arteries. By echocardiography, a giant thrombus was detected in the left atrium with severe mitral stenosis. Thrombectomy and angioplasty were performed at about 5 hours after the onset of occlusion, and revascularization was successful. Three days after the operation, we excised the giant thrombus in the left atrium and performed mitral valve replacement because we considered that myonephropathic metabolic syndrome (MNMS) had been prevented. The postoperative course was uneventful and he was discharged on the 27th postoperative day.

Autoantigenicity of carbonic anhydrase 1 in patients with abdominal aortic aneurysm, revealed by proteomic surveillance.

Abdominal aortic aneurysm (AAA) is sometimes detected in patients with atherosclerosis. One of the histological characteristics of AAA walls is infiltration of inflammatory cells, in which autoimmunity may be involved. Thereby, we here surveyed autoantigens in AAA walls by proteomics. Specifically, we separated proteins extracted from AAA wall samples by 2-dimensional electrophoresis and detected candidate autoantigens by western blotting. One of the detected candidates was carbonic anhydrase 1 (CA1). ELISA confirmed that the autoantibodies to CA1 were detected more frequently in AAA patients (n=13) than in healthy donors (n=25) (p=0.03). Interestingly, some serum samples from the AAA patients reacted to CA1 of the AAA walls stronger than to CA1 of peripheral blood mononuclear cells from healthy donors. Our data indicate that CA1 in the AAA walls would be modified to express neo-epitope(s) and that the autoimmunity to CA1 may be involved in the pathogenesis of AAA.

Surgical treatment or conservative therapy for stanford type a acute aortic dissection with a thrombosed false lumen.

OBJECTIVES: Optimum treatment for acute aortic dissection (AAD) with a thrombosed false lumen (thrombosed AAD) remains controversial. We evaluated the outcome of thrombosed AAD according to treatment strategy. MATERIALS AND METHODS: We examined 280 patients with AAD, of which 30 had thrombosed AAD. We compared computed tomography findings, cardiac performance, and clinical course in 28 of these patients. Patients were divided into three groups for the comparison: Group E (emergency surgery), Group C (conservative therapy), and Group S (conservative therapy switched to emergency surgery). RESULTS: In Group E (n = 13), one patient died and 12 survived. In Group C (n = 10), all patients were discharged, of which two died of cancer and two of the remaining eight survivors underwent subsequent elective surgery. In Group S (n = 5), one patient died and four survived following surgery. CONCLUSIONS: It was hard to predict re-dissection or rupture following conservative treatment for thrombosed AAD. Basically, we should perform emergency surgery following the diagnosis of thrombosed AAD, particularly in complicated cases such as those with pericardial effusion, tamponade, and large aorta. Conservative therapy has a very limited application in patients with the initial stages of thrombosed AAD.

Reports of four surgical treatments of acute pulmonary embolism with a floating thrombus in the right atrium.

Acute pulmonary embolism (APE) is a serious disease. Recently, multidetector-row computed tomography (MDCT) has proven to be valuable in detecting APE and deep vein thrombosis. APE is classified as massive, submassive, and nonmassive. The incidence of submassive APE and the number of therapeutic approaches for clinically diagnosed critical submassive APE have both increased. However, most strategies for submassive APE have been conservative, e.g., transvenous catheter pulmonary embolectomy, and there are few reports on surgical pulmonary embolectomy. We examined the surgical outcomes in four cases of submassive APE with a floating thrombus in the right atrium (RA) from August 2003 to July 2008. All patients appeared to have no neurological complications and showed an event-free survival of up to 65 months (37 ± 25 months). Surgical pulmonary embolectomy was effective for submassive APE with a floating thrombus in the RA.

Communication between the right pulmonary artery and left atrium with aneurysm formation.

Communication between the pulmonary artery and the left atrium is a rare congenital anomaly. A 7-year-old boy was referred to our hospital with a diagnosis of pulmonary arteriovenous fistula. Referral to a pediatric cardiologist had been delayed because he had only slight cyanosis and no heart murmur. Catheterization and computed tomography scans confirmed that the right pulmonary branches and pulmonary venous returns were normal and that an additional aneurysmal communication was located between the right pulmonary artery and the left atrium. Surgery proceeded uneventfully together with a cardiopulmonary bypass. The connection from the right pulmonary artery to the aneurysm was ligated, and the connection from the left atrium to the aneurysm was closed with a polytetrafluoroethylene patch. We describe this rare anomaly with cyanosis and no heart murmur.

Recurrent coarctation of the aorta: a patient with bilateral persistent sciatic arteries.

A 19-year-old female was referred to our department with a diagnosis of recurrent coarctation of the aorta. She had undergone end-to-side anastomosis of the left subclavian artery with the thoracic aorta at 9 days of age and extra-anatomic subclavian-to-femoral bypass grafting at 15 years of age because of hypertensive crisis. A preoperative 4-slice computed tomography (CT) scan demonstrated recurrent obstruction of the aorta and, unexpectedly, an associated anomaly of bilateral persistent sciatic arteries. She underwent a successful patch augmentation of the aorta and is currently leading a normal life without need for antihypertensive medication. Persistent sciatic artery is a rare congenital vascular anomaly and is known to develop aneurysm or critical lower limb ischemia. To our knowledge, this is the first report of a patient with coarctation of the aorta and bilateral persistent sciatic arteries.

Gorlin formulas for aortic regurgitant and mitral regurgitant orifice areas: experimental studies.

BACKGROUND AND OBJECTIVES: The measurement of aortic regurgitant and mitral regurgitant orifice areas has recently been pioneered. The present study tried to establish Gorlin formulas for aortic regurgitant and mitral regurgitant orifice areas for evaluating the severity of aortic regurgitation and mitral regurgitation. METHODS: Seventeen stable hemodynamic states for mitral regurgitation and 22 for aortic regurgitation were studied in sheep. Aortic regurgitant and mitral regurgitant orifice areas were determined by dividing regurgitant volume per second by the time integrals of the continuous aortic regurgitant and mitral regurgitant wave velocities. Aortic regurgitant and mitral regurgitant orifice areas calculated by the formulas using echocardiographic data were compared with other measurements by electromagnetic flowmeters. RESULTS: The Gorlin formulas were aortic regurgitant orifice area = per second valve flow/ 50.7 square root mean pressure gradient, and mitral regurgitant orifice area = per second valve flow/ 27.5 square root mean pressure gradient. Simple linear analysis between aortic regurgitant fractions, regurgitant volume per beat and peak aortic regurgitant flow rates, and aortic regurgitant orifice areas derived from the formula showed moderately good relationships (r = 0.73, 0.81 and 0.83). Mitral regurgitant orifice areas calculated by the formula also correlated with mitral regurgitant fractions, regurgitant volume per beat and peak mitral regurgitant flow rates (r = 0.86, 0.92 and 0.74). CONCLUSIONS: The Gorlin formulas for aortic regurgitant and mitral regurgitant orifice area may provide an index for evaluating the severity of regurgitation.

Noonan syndrome associated with anomalous coronary artery and other cardiac defects.

This case-report describes an 11-month-old infant, who had been diagnosed with Noonan syndrome with a variety of associated anomalies. Multiple cardiac anomalies were present, consisting of dysplastic pulmonary valve, symmetric biventricular hypertrophy, atrial septal defect and right ventricular outflow tract (RVOT) obstruction, in which the pressure gradient measured 73 mmHg, and anomalous coronary artery. Systolic anterior motion of the mitral valve (SAM) was present, without remarkable clinical significance. RVOT transannular repair with non-cusped xenograft along with resection of hypertrophied right ventricular outflow myocardium. Left ventricular outflow tract (LVOT), which had no clinical sign of obstruction, was left untouched, expecting the RVOT repair also effectively release LVOT dynamic obstruction. The postoperative echocardiography revealed residual SAM without significant pressure gradient through LVOT.

An experimental study of surgical ultrasonic angioplasty: its effect on atherosclerosis and normal arteries.

BACKGROUND: We have developed a new hand-held probe for surgically open ultrasonic angioplasty. Two experimental studies were conducted to determine the optimal power range for carrying out ultrasonic angioplasty. METHODS: The probe measured 2.5 mm in diameter and 5 cm in length. The amplitude was 210 microm at 100% power. One of the studies was designed to determine the power range that is effective for removal of atherosclerotic lesions. Human cadaveric arteries were used in the study. The other study was designed to investigate the long-term adverse effect on normal arteries. Canine arteries were used in this study. RESULTS: In the study using cadaveric arteries, the amplitude ranging from 90 to 110 microm was effective for soft atheroma, the range from 110 to 130 microm was effective for mild arteriosclerosis, and 150 microm was effective for calcified lesions. The other study of the long-term effect on canine normal arteries indicated that each incidence of stenosis and occlusion was 0% at amplitude ranging from 90 to 110 microm, 13% at 130 microm, and 25% at 150 microm. CONCLUSIONS: The surgically open ultrasonic angioplasty with a new hand-held probe was effective for various kinds of atherosclerotic lesions, whereas the angioplasty at high amplitude had a problem with the long-term effect on normal arteries.

Mitral valve replacement in a 15-month-old infant with infective endocarditis.

This report describes a 15-month-old child without particular heart problems, presenting prolonged high-grade fever, an impaired level of consciousness, right hemiparesis and cutaneous lesion on admission. Medication was started according to the initial diagnosis of bacterial or viral meningitis, however, congestive heart failure was suddenly observed 15 days after the admission. Echocardiography revealed a mass in the right atrium, and mitral valve regurgitation due to the irregularly thickened and aneurysmal anterior leaflet with a perforation, consistent with infective endocarditis. Mitral valve replacement with a mechanical prosthesis was performed and the postoperative course was uneventful.

Mortality of pulmonary artery banding in the current era: recent mortality of PA banding.

BACKGROUND: The mortality of pulmonary artery banding improved significantly in the 1980s. However, we lack information on this procedure in the current era. METHODS: The results of pulmonary artery banding in 365 patients who had operations between 1966 and 2001 were reviewed. The patients were divided into three groups: (1) group 1 patients who had operations between 1966 and 1979, (2) group 2 patients who had operations between 1980 and 1989, and (3) group 3 patients who had operations between 1990 and 2001. RESULTS: Significantly younger and smaller patients have been operated on recently (mean age: group 1, 169.0 +/- 40 days; group 2, 101.8 +/- 11 days; and group 3, 69.7 +/- 8.9 days; and mean weight: 4.6 +/- 0.1, 4.1 +/- 0.1, and 3.2 +/- 0.1 kg, respectively). A decrease was found in the number of simple cardiac anomalies, such as isolated ventricular septal defects. The early mortality in the three groups was 38.3% for group 1 (65 of 187), 13.5% for group 2 (15 of 111), and 13.8% for group 3 (12 of 87). Although the mortality did not vary significantly between groups 2 and 3, it improved over time in patients weighing less than 3 kg. Multivariate analysis of group 3 demonstrated that no isolated variable, including sex, weight, and diagnosis was a significant risk factor. CONCLUSIONS: Despite the advances in perioperative management, we found no improvement in the early mortality of pulmonary artery banding during the last decade. These results will support the preference for primary repair of intracardiac anomalies in small infants. However, this operation can now be performed with the same risk even in smaller patients. We believe that pulmonary artery banding has a role in the treatment of congenital cardiac anomalies.

Dilatable banding of a Blalock-Taussig shunt.

Dilatable banding has been used in various situations. Sometimes Blalock-Taussig shunt banding is performed to prevent pulmonary overcirculation. Recently several reports have described dilatable pulmonary artery banding. We modified these methods for flow control of a Blalock-Taussig shunt. We report the case of a neonate with truncus arteriosus in which this technique was used.

Aortopulmonary window due to balloon angioplasty after arterial switch operation.

We report 2 cases of aortopulmonary window that developed after balloon angioplasty for pulmonary artery stenosis. Both patients had undergone arterial switch operations for complete transposition of the great arteries before the angioplasty. These aortopulmonary windows were repaired through elective operations. The clinical features, diagnosis, management, and proposed mechanisms of this complication are described.