Reoperative aortic valve replacement after bio-Bentall using a double sewing ring technique.

We report an 89-year-old haemodialysis patient with a structural valve deterioration following a Bentall-de Bono operation with a tissue valve using the double sewing ring technique. The bioprosthesis was extracted easily, and the aortic valve replacement was performed without any complications in a high-risk patient. This procedure may be feasible given the prospects of reoperation.

A case of aortoduodenal fistula presenting with postoperative lymphatic leakage.

INTRODUCTION AND IMPORTANCE: Secondary aortoduodenal fistula (sADF) is a complication of prosthetic graft replacement of the abdominal aorta which often follows a fatal course. This report details our experience with a case of lymphatic fistula that developed after sADF repair. The fistula was refractory to conservative treatment but ultimately responded to lipiodol lymphangiography. CASE PRESENTATION: A 75-year-old man had undergone prosthetic graft replacement to treat an abdominal aortic aneurysm in 2012 and a thoracic aortic aneurysm in 2015. Upper gastrointestinal endoscopy was performed in 2020, and examination for worsening anemia revealed that the abdominal aortic graft had eroded into the horizontal duodenum. The patient was treated with prosthetic graft replacement and duodenectomy. A refractory lymphatic fistula was noted after surgery, which made ascites accumulation difficult to control, but the patient's condition rapidly improved following therapeutic lymphangiography. CLINICAL DISCUSSION: Surgery is the first-line therapy for sADF, but clinicians must stay vigilant for infection recurrence and aortoenteric fistulae after a repair, and this requires patient-specific postoperative management. Our modifications, intended to minimize contamination of the operative field in the present case, also facilitated our ability to subsequently treat a refractory lymphatic fistula, which is a rare postoperative complication of the procedure. CONCLUSION: Procedural modifications to sADF repair aimed at minimizing perioperative contamination are crucial for preventing infection recurrence. Given the extent of invasion, the surgery can cause various postoperative complications, requiring individualized strategies for management and treatment. Therapeutic lymphangiography is one such approach, which holds promise as a first-line treatment for refractory lymphatic fistula.

Repair of insufficient aortic valve and single coronary artery with intramural course.

We report about a patient with severe bicuspid aortic valve insufficiency and a single coronary artery with an intramural course. Aortic valve repair with double plication and coronary translocation was satisfactory.

[Strategy to Avoid Reoperation after Ascending Aortic Replacement for DeBakey Typeâ Acute Aortic Dissection].

When ascending aortic replacement (AAR) is performed in patients with DeBakey typeⅠ acute aortic dissection( AAD), residual false lumen of the aortic arch after AAR is a risk factor of remote aortic reoperation. We have principally considered entry resection as a surgical policy for AAD, but since 2013, for cases of re-entry in the brachiocephalic artery, reconstruction of the brachiocephalic artery has been added. We verified whether brachiocephalic artery reconstruction contributes to the thrombus closure of the false lumen of the aortic arch after the operation. Of 68 patients who underwent AAR for DeBakey typeⅠ AAD within a 12 year period, 17 had re-entry in the brachiocephalic artery on preoperative computed tomography (CT). Six patients who underwent brachiocephalic artery reconstruction were assigned to group A, and 11 patients who did not were assigned to group B. We compared the 2 groups. Aortic clamp and selective cerebral perfusion times were significantly longer in group A. By postoperative CT, false lumen of the aortic arch was not found in any case (0%) in group A, but was found in 10( 90.9%) of the 11 cases in group B( p=0.0006). The risk of residual false lumen of the aortic arch significantly decreased in group A. In conclusion, in cases where re-entry is found in the brachiocephalic artery, a false lumen often remains in the aortic arch after AAR. However, by reconstructing the dissected brachiocephalic artery, the false lumen of the aortic arch can be obliterated, which contributes to avoidance of reoperation in a chronic phase.

[Distal Stentgraft-induced New Entry Developed after Surgery for Aortic Dissection].

We experienced 2 cases with distal stentgraft-induced new entry (distal SINE) after thoracic endovascular aortic repair( TEVAR) for type B aortic dissection and 1 case after total arch replacement and frozen elephant trunk method for type A dissection. We successfully performed additional TEVAR in all cases. If the stent graft is bent at deployment, distal SINE may occur on the great curvature side of the aorta by the spring back force. Therefore, we must pay attention to appropriate device selection, and even when remodeling of the aorta is good, meticulous follow-up is necessary.

PPAR-γ agonist attenuates inflammation in aortic aneurysm patients.

BACKGROUND AND OBJECTIVE: Peroxisome proliferator-activated receptor (PPAR) -γ agonist, which is an anti-diabetes drug and reduces expression of tumor necrosis factor (TNF)-α, reported to have the effects for anti-inflammation in our body. In cardiovascular fields, this PPAR-γ agonist already reported to suppress progression of coronary atherosclerosis. Various cytokines, which is secreted from fat tissues around artery, promote atherosclerosis and/or aneurysmal changes in aorta/artery. Objective of our study is to clarify whether PPAR-γ agonist has anti-inflammatory effects in aorta of patients with aortic aneurysm (AA). PATIENTS AND METHODS: The medical ethics committee in Tokushima University Hospital approved protocol for this study. Sixteen patients with AA (more than 5 cm in diameter, scheduled open surgery) were divided into two groups; one is PPAR-γ agonist administrating group [Formula: see text] n = 6, group P[Formula: see text], and another is the without group [Formula: see text] n = 10, group C[Formula: see text]. PPAR-γ agonist, whose dose was 15 mg/day, was administrated in the group P for more than 2 months before aneurysectomy and grafting (mean; 4.2 ± 3.4 months) (Supplemental Table 1). Biopsy specimens were obtained from abdominal subcutaneous fat, greater omentum, retroperitoneal periaortic fat and aneurysmal wall in surgical procedure. Blood examination also achieved before/after procedure. Harvested specimens were analyzed with histology (HE and EVG), immunohistochemistry (macrophage) and RT-PCR (adiponectin, MCP-1, TNF-α, CD68, matrix metalloprotease (MMP)-2, MMP-9). RESULTS: Macrophage infiltration in aortic wall and retroperitoneal periaortic fat among group P was significantly decreased compared to that among group C. Adiponectin expressions in both subcutaneous fat and retroperitoneal periaortic fat among the group P (adiponectin/ß-actin) were significantly increased compared to those among the group C [subcutaneous fat; 16.8 ± 13.9 vs. 5.82 ± 2.94 (P = 0.04), retroperitoneal periaortic fat; 21.3 ± 24.1 vs. 2.12 ± 1.69 (P = 0.04)]. On the other hand, expressions of TNF-α, and MMP-9 in both aortic aneurysmal wall and retroperitoneal periaortic fat among group P were significantly decreased. [(Aortic aneurysmal wall; TNF-α; 0.45 ± 0.15 vs. 5.18 ± 3.49 (P = 0.02), MMP-9; 39.6 ± 69.0 vs. 721 ± 741 (P = 0.04)], [retroperitoneal periaortic fat; TNF-α; 1.14 ± 0.36 vs. 26.4 ± 25.0 (P = 0.048), MMP-9; 0.18 ± 0.21 vs. 50.0 ± 41.8 (P = 0.047)]. CONCLUSION: These data may indicate that PPAR-γ agonist become the way for preventing or delaying aortic aneurysm progression in patients. More studies will be needed to clarify this drug effects in detail.

[Patch plasty of intraoperative acute aortic dissection in a patient with severe aortic valve stenosis;report of a case].

Intraoperative aortic dissection is a rare complication, but is associated with a high mortality. We report a case of 79-year-old woman with severe aortic valve stenosis who underwent aortic valve replacement(AVR). After cardiopulmonary bypass(CPB) was established, aortic dissection started at the inflow cannulation site. Because hemodynamics were stable, we performed AVR as scheduled. After declamping, excessive bleeding from the arterial cannulation site continued. CPB was reestablished by placing the arterial cannula in the left femoral artery. The ascending aorta was opened at the site of cannulation under deep hypothermic circulatory arrest. The entry tear was successfully repaired by entry resection and Hemashield patch plasty. The postoperative course was uneventful, and the patient was discharged on the 22nd postoperative day. Patch plasty may be useful for the management of intraoperative aortic dissection.

A Case of Coronary Artery Bypass Grafting for Anomalous Aortic Origin of a Coronary Artery / 日本心臓血管外科学会雑誌

Anomalous aortic origin of a coronary artery (AAOCA) can cause sudden death, especially in young athletes. AAOCA does not have any clinical cardiovascular manifestations and sudden death is often the first manifestation ; hence, it is difficult to diagnose AAOCA before a major episode occurs. We report the case of a 58-year old woman with a right coronary artery arising from the left sinus and passing between the aorta and the pulmonary artery. Although the results of the exercise treadmill test and various other tests were normal, this patient underwent coronary artery bypass, surgery using the right internal thoracic artery to preventing sudden death. Two years after the operation, she is asymptomatic and has normal results on the exercise treadmill test.

Coronary atherosclerosis is associated with macrophage polarization in epicardial adipose tissue.

OBJECTIVES: The purpose of this report was to assess the link between macrophage polarization in epicardial adipose tissue and atherosclerosis in patients with coronary artery disease (CAD). BACKGROUND: Macrophage accumulation enhances chronic inflammation in adipose tissue, but macrophage phenotypic change in human epicardial adipose tissue and its role in atherogenesis are unknown. METHODS: Samples were obtained from epicardial and subcutaneous adipose tissue during elective cardiac surgery (CAD, n = 38; non-CAD, n = 40). Infiltration of M1/M2 macrophages was investigated by immunohistochemical staining with antibodies against CD11c and CD206, respectively. Expression of pro- and anti-inflammatory adipocytokines in adipose tissue was evaluated by real-time quantitative polymerase chain reaction. RESULTS: Infiltration of macrophages and expression of pro- and anti-inflammatory cytokines were enhanced in epicardial fat of patients with CAD compared with that in non-CAD patients (p < 0.05). The ratio of M1/M2 macrophages was positively correlated with the severity of CAD (r = 0.312, p = 0.039). Furthermore, the expression of pro-inflammatory cytokines was positively correlated, and the expression of anti-inflammatory cytokines was negatively correlated with the ratio of M1/M2 macrophages in epicardial adipose tissue of CAD patients. By contrast, there was no significant difference in macrophage infiltration and cytokine expression in subcutaneous adipose tissue between the CAD and non-CAD groups. CONCLUSIONS: The ratio of M1/M2 macrophages in epicardial adipose tissue of CAD patients is changed compared with that in non-CAD patients. Human coronary atherosclerosis is associated with macrophage polarization in epicardial adipose tissue.

Functional restoration of endothelial cells of the cryopreserved heart valve.

PURPOSE: Although several approaches have been tried to improve the durability of cryopreserved valves, cellular restoration after thawing remains to be investigated. The aim of our study was to assess the functional restoration of endothelial cells of cryopreserved heart valves by in vitro culture for an alternative step to improving longevity. METHODS: Cryopreserved human umbilical vein endothelial cells (HUVECs) and porcine aortic cusps were cultivated for 14 days after thawing. Then the cellular activity of the enzymes cytosolic esterase and mitochondrial dehydrogenase was measured. The cellular viability of cryopreserved cusps was also assessed using confocal laser scanning microscopy. RESULTS: The number of viable HUVECs decreased markedly after cryopreservation and thawing but recovered to pre-cryopreservation level after 14 days of culture. In contrast, the enzyme activity of the cryopreserved porcine aortic cusps showed recovery at 7 days of in vitro tissue culture after thawing. Confocal laser scanning microscopy findings showed that the cellular cytosolic esterase activity of cryopreserved cusps deteriorated after thawing but displayed considerable recovery by day 14 of culture. CONCLUSION: The functional recovery of endothelial cells in cryopreserved heart valves seems to require tissue culture of at least 14 days. Ex vivo endothelial restoration of cryopreserved heart valves may add to heart valve durability.

Successful early resection of cardiac papillary fibroelastomas.

Two adult patients with previous transient cerebral ischemic attacks (TIAs) or chest oppression were referred for further investigation. A swaying pedicled tumor was detected in the left atrium of the former patient and in the left coronary cusp of the latter by echocardiography. The TIA, or angina-like attack, was anticipated to be caused by thromboembolism of the tumor. Both patients underwent tumor extirpation. The histological findings demonstrated that both tumors were benign papillary fibroelastoma limited to the endocardium/endothelium layer. In conclusion, early surgical resection of a cardiac papillary fibroelastoma should be performed.

Syngeneic bone marrow mononuclear cells improve pulmonary arterial hypertension through vascular endothelial growth factor upregulation.

BACKGROUND: We investigated the effects and possible mechanism of syngeneic bone marrow mononuclear cell (BM-MNC) transplantation on pulmonary arterial hypertension induced by monocrotaline. METHODS: Monocrotaline (80 mg/kg body weight) was administrated to C57BL/6 mice, and pulmonary arterial hypertension was induced 4 weeks later. Bone marrow mononuclear cells harvested from syngeneic donor mice were injected intravenously into those mice 4 weeks after monocrotaline administration. The ratio of right ventricular to septum plus left ventricular weight, the number of small pulmonary arteries, and medial thickness of pulmonary arteries were measured. Western immunoblotting of the lung tissue was performed to observe vascular endothelial growth factor and its receptor expression 1 week after BM-MNC transplantation. Vascular endothelial growth factor receptor-2 inhibitor was administered to pulmonary arterial hypertension mice simultaneously with BM-MNC transplantation. RESULTS: The ratio of right ventricular to septum plus left ventricular weight increased, the number of pulmonary arteries decreased, and medial thickness increased significantly 4 weeks after monocrotaline injection compared with those of vehicle-injected mice. These indices of monocrotaline-injected mice improved significantly 4 weeks after BM-MNC transplantation compared with those of mice at 8 weeks after monocrotaline injection (0.22 +/- 0.02 versus 0.31 +/- 0.02; 17.1 +/- 2.6 versus 8.2 +/- 1.7; 7.7% +/- 2.2% versus 20% +/- 2.1%, respectively; p < 0.01). However, BM-MNCs were not incorporated into the lung at 1 week after transplantation, and significant vascular endothelial growth factor upregulation and without receptor expression was observed in lung tissue 1 week after transplantation. Improvement of pulmonary arterial hypertension was inhibited by simultaneous administration of vascular endothelial growth factor receptor-2 inhibitor with BM-MNC transplantation. CONCLUSIONS: These results indicate that syngeneic BM-MNC transplantation improves monocrotaline-induced pulmonary arterial hypertension by favorable pulmonary artery remodeling through vascular endothelial growth factor upregulation.