[Asymptomatic Chronic Expanding Hematoma Following Previous Cardiac Surgery Diagnosed by Computed Tomography-guided Biopsy:Report of a Case].

A 48-year-old man was referred to our hospital with an intrapericardial mass, which was incidentally found by computed tomography( CT) in a health check-up. He had undergone surgical closure of atrial septal defect 23 years ago. Although echocardiography and CT revealed compression of the right ventricle by a mass, he had no symptoms and echocardiography revealed no significant right ventricular overload. Magnetic resonance imaging revealed a mosaic pattern of various signal intensities. We performed a CT-guided biopsy, and the histological result was a hematoma. This was the first reported case of chronic expanding hematoma following previous cardiac surgery diagnosed by CT-guided biopsy.

The endoscopic no-touch saphenous vein harvesting technique.

The no-touch saphenous vein harvesting technique is being increasingly used; however, this technique causes more leg wound complications than conventional techniques. Endoscopic saphenous vein harvesting is considered a safe and effective approach for reducing leg complications, despite the fact that experience with this technique remains limited, because leg CO2 insufflation and dissection with a tip cannula to isolate the vein enables the graft to naturally skeletonize.  In this video tutorial, we demonstrate our endoscopic no-touch saphenous vein harvesting technique using a reusable saphenous vein retractor system without CO2 insufflation and an electrothermal bipolar vessel sealing device.

Use of the No-Touch Saphenous Vein Harvesting Technique via Small Incisions.

There are substantial data in support of improved patency using the no-touch (NT) saphenous vein (SV) harvesting technique. However, wound complications correlated with such are more significant than those associated with the skeletonized technique. To solve this, we introduced the use of the electrothermal bipolar vessel sealing device via small incisions. In this study, a cordless retractor with a built-in LED light source was utilized. The NT-SV graft was harvested with a pedicle of surrounding tissue approximately 5 mm in size and attached to the main trunk. The intima, tunica media, adventitia, and vasa vasorum appeared normal by histological analysis. Our technique combines the potential advantages of a minimally invasive endoscope approach using bipolar electrothermy and the improved patency of a NT-SV.

Forced oscillation technique as a predictor of FEV1 improvement in asthma.

The usefulness of the forced oscillation technique (FOT) for predicting the treatment outcomes in untreated asthmatic patients is unknown. We investigated whether FOT could predict an improvement in FEV1 following treatment. FOT, spirometry, and fractional exhaled nitric oxide were performed in 31 outpatients before and after undergoing a minimum of two months combination therapy of inhaled corticosteroids and long-acting ß2-agonists. The patients were classified as responders or nonresponders to treatment based on the presence or absence of a 10% improvement in the FEV1. The responders to the treatment regimen exhibited lower FEV1, FEV1/FVC, FEF25-75%, and higher respiratory resistance at 5Hz (R5), as well as a difference between R5 and R20 (R5-R20) at baseline compared to the nonresponders. In the multivariate logistic regression analyses, a change in FEV1 greater than 10% was independently predicted by the R5 (adjusted odds ratio: 15.9). The ROC curve analyses revealed that the area under the curve for R5 (0.731) was larger than that of the other parameters. Thus, R5 is a forced oscillatory parameter and predicts an improvement in FEV1 following treatment.

Association of the forced oscillation technique with negative expiratory pressure in COPD.

Expiratory flow limitation (EFL) during tidal breathing is common in patients with severe COPD, and a major determinant of dynamic hyperinflation and exercise limitation. The negative expiratory pressure (NEP) technique has been the gold standard to detect EFL, while the forced oscillation technique (FOT) has also been reported to detect it. However, the association of FOT with NEP is not fully understood. We assessed whether broadband frequency FOT would predict the presence of EFL measured by NEP. FOT, NEP, and spirometry were performed in 51 patients with COPD. The extent of emphysema was measured by high-resolution computed tomography and scored. Fifteen patients were classified into the EFL-positive group and 36 into the EFL-negative group. In multivariate logistic regression analysis, EFL was independently predicted by emphysema score, forced vital capacity, and whole-breath respiratory system reactance at 5Hz (X5). The receiver operator characteristic curve analysis revealed that inspiratory X5 best predicted EFL-positivity. X5-related forced oscillatory parameters are useful for detecting EFL in the management of COPD.

Aneurysm growth after late conversion of thoracic endovascular aortic repair.

A 69-year-old man underwent thoracic endovascular aortic repair of a descending aortic aneurysm. Three years later, he developed impending rupture due to aneurysmal expansion that included the proximal landing zone. Urgent open surgery was performed via lateral thoracotomy, and a Dacron graft was sewn to the previous stent graft distally with Teflon felt reinforcement. Postoperatively, four sequential computed tomography scans demonstrated that the aneurysm was additionally increasing in size probably due to continuous hematoma production, suggesting a possibility of endoleaks. This case demonstrates the importance of careful radiologic surveillance after endovascular repair, and also after partial open conversion.

Left ventricular external buttress technique for repair of ventricular septal perforation†.

Because of the difficulty in placing a suture-supporting extension to a non-infarcted area, ventricular septal perforation repair in the presence of large myocardial infarctions can give rise to life-threatening tears or ruptures of the left ventricular free wall. We report a case of successful reinforcement of an infarction area from outside of the left ventricle using a large, thick polytetrafluoroethylene felt patch. After surgery, the patient was weaned from cardiopulmonary bypass without difficulty. Postoperative echocardiography revealed no residual shunting and he was alive without complications 3 years after surgery.

Polyglycolic acid sheet with fibrin glue potentiates the effect of a fibrin-based haemostat in cardiac surgery.

BACKGROUND: Hemorrhage from the left ventricle can be critical and sutureless repair using a fibrin-based haemostat (TachoComb) is one effective option. When active hemorrhage is not controlled by the haemostat, we have used a polyglycolic acid (PGA) sheet and fibrin glue in addition. Here we investigated whether the PGA sheet and fibrin glue combined with TachoComb had stronger adhesive properties than TachoComb alone in two experimental models. METHODS: Experiment 1. An airtight circuit that included rabbit skin with holes covered by each type of sealant was gradually pressurized and the burst pressure was recorded automatically (n = 10). Experiment 2. A suture loop was attached to a porcine heart by each sealant, and the peel-off pressure was measured (n = 12). RESULTS: The PGA sheet and fibrin glue combined with TachoComb showed significantly higher adhesive strength than TachoComb alone in both experiments (p < 0.05). CONCLUSIONS: Adding a PGA sheet and fibrin glue increased the adhesive strength of TachoComb in two experimental models, suggesting that this method might be effective for achieving haemostasis in difficult clinical situations.

A papillary-ventricular complex repair technique for functional mitral regurgitation.

The objective of this study was to describe a simple and reproducible papillary-ventricular complex technique for repairing functional mitral regurgitation. To avoid a recurrence of mitral regurgitation subsequent to left ventricular remodelling, we performed papillary muscle plication and papillary muscle and head approximation in combination with relocation of the papillary muscle heads to correct any anterior and or posterior mitral leaflet discrepancy and to preserve the papillary-ventricular complex. Preliminary results in 7 patients showed an encouraging functional improvement following surgery. Future long-term controlled studies in a greater number of patients are required to further assess this novel technique.

Pseudo systolic anterior motion: potential for severe mitral regurgitation after aortic valve replacement.

A 68-year-old man with severe aortic stenosis (AS) and marked left ventricular hypertrophy (LVH), underwent aortic valve replacement (AVR). Preoperative echocardiography demonstrated contact between the anterior mitral leaflet and the interventricular septum during diastole without mitral regurgitation (MR), i. e., "pseudo systolic anterior motion (SAM). " After a mechanical prosthesis had been implanted, severe mitral regurgitation MR and pulmonary hypertension occurred due to "true" SAM of the mitral valve. Despite intensive management, it was difficult to control MR in the acute phase.In the chronic phase, echocardiography revealed the resolution of both SAM and MR. It is suggested that the dramatic reduction of afterload after alleviation of valvular stenosis by prosthetic replacement and increased flow velocity in the left ventricular outflow tract (LVOT) caused SAM with MR. The risk of SAM after AVR should be considered in AS patients with marked LVH, especially in the presence of "pseudo SAM. "

Using a double-plicated posterior leaflet as an anchor for mitral valve replacement: a case of mitral annular calcification.

We present a 62-year-old man with mitral regurgitation whose posterior annulus had severe calcification. Mitral valve replacement was performed by anchoring the cuff on a double-plicated posterior leaflet, and reinforcing with an equine pericardium. The patient is doing well 13 years after surgery with echocardiography showing no problems.

[A patient with advanced remnant gastric cancer responding completely to S-1 monotherapy].

A 74-year-old man with anemia visited our hospital. When he was 42 years old, he was diagnosed with duodenal ulcer and underwent gastrectomy with Billroth II construction. A gastrointestinal endoscopic examination revealed an ulcerative lesion at the remnant stomach, and the pathological examination of the biopsy specimen showed moderate to poorly differentiated adenocarcinoma. Abdominal CT scan revealed liver and para-aortic lymphnode metastases. He received daily oral administration of S-1 at a dose of 100 mg/body, bid, 4 weeks on and 2 weeks off. After 4 courses of S-1, CT scan showed a complete response of the liver and also para-aortic lymphnode metastasis. He underwent total remnant gastrectomy with D2 dissection. Histological examination revealed no residual cancer cells in the surgically removed stomach and lymphnode, and he was diagnosed a complete pathological response (Grade 3). He refused adjuvant S-1, but is in good health without recurrence 2 years after the operation.

Paraplegia due to spinal epidural hematoma after mitral valve surgery: report of a case.

Spinal epidural hematomas are rare entities that can be associated with spinal traumatic injuries and vascular lesions or that can spontaneously arise. Several reports have linked these hematomas to heart valve surgery. We herein describe a 71-year-old female patient who developed postoperative paraplegia immediately after mitral valve repair. Magnetic resonance imaging revealed an epidural hematoma of the spinal cord from C7 to Th4. A laminectomy was not performed because the patient's paraplegia gradually improved. After continuous rehabilitation, the patient regained sufficient muscle strength to perform standing exercises. She is presently capable of routine activities at home and is undergoing bethanechol chloride treatment for a neurogenic urinary bladder. Motor and sensory deficits of both lower limbs in a patient that arise immediately after heart surgery must be examined by early imaging to rule out space-occupying pathologies such as spinal epidural hematomas.

Graft fixation with a side graft holder for sequential and composite graft anastomosis in coronary artery bypass surgery.

The purpose of this study was to assess the feasibility and effectiveness of graft fixation with a novel side graft holder for sequential or composite graft anastomosis in coronary artery bypass grafting (CABG). Records of 34 patients who underwent CABG using sequential or composite graft anastomosis technique were reviewed. The device was used on 47 anastomoses (sequential=43; composite graft=4). Excellent fixation and visualization of the graft was obtained in all patients without graft injury. Postoperative angiographic patency rate of distal anastomoses was 95.2% (arterial, 91.2%; venous, 96.7%). All sequential and composite graft anastomoses were patent and without stenosis. One operative death occurred due to low cardiac output after emergent CABG for acute myocardial infarction. No elective patient died during hospitalization. Postoperative complications occurred in two patients (ventricular fibrillation, 1; postoperative catheter intervention, 1). No perioperative myocardial infarctions or re-operations occurred. Our clinical experience shows that graft fixation with the device is safe, reliable, and effective for sequential and composite graft anastomosis during CABG.

A simple and safe technique for positioning a bipolar radio-frequency device for pulmonary vein isolation.

We describe a simple and safe technique to position a bipolar radio-frequency ablation device around the pulmonary veins when performing pulmonary vein isolation. The technique consists of insertion of a rubber catheter with stylet, originally an introducer from a left vent catheter, behind the pulmonary veins, and subsequent placement of the lower jaw of the ablation clamp using a rubber catheter to guide the device into position. This novel method avoids excessive compression or displacement of the heart and enables easy and safe positioning of the ablation device around the pulmonary veins.

A novel side graft holder for coronary artery bypass grafting.

We describe the construction and use of a novel side graft holder for coronary artery bypass grafting. The device is a hammer head-shaped clip used to hold the graft side securely but atraumatically during sequential or composite graft anastomosis. The side graft holder provides gentle stabilization and excellent visualization of the side of the graft without causing graft injury.

Platelets activated by collagen through the immunoreceptor tyrosine-based activation motif in the Fc receptor gamma-chain play a pivotal role in the development of myocardial ischemia-reperfusion injury.

Platelet activation and the formation of platelet microaggregates in coronary vessels play pivotal roles in myocardial ischemia and reperfusion injury. The Fc receptor gamma-chain (FcR gamma) is coexpressed with glycoprotein (GP) VI, forming a platelet collagen receptor, and the activation of platelets by collagen is closely coupled with tyrosine phosphorylation of the FcRgamma. To examine the functional significance of platelet FcR gamma/GPVI complex in the early phase of myocardial ischemia and reperfusion injury in mice, we performed coronary occlusion and reperfusion experiments using wild type mice and FcRgamma-deficient (FcRgamma(-/-)) mice that lack GPVI. The infarct size was significantly smaller in FcRgamma(-/-) mice subjected to occlusion and reperfusion of the coronary artery than in control FcR gamma(+/+) mice. Twenty-four hours after the reperfusion, electron microscopy of the injured tissue showed substantially more platelet aggregation and occlusive platelet microthrombi in the capillaries of the damaged areas of the wild type mice than in those of the FcR gamma(-/-) mice. Platelet Syk was scarcely activated in the FcR gamma(-/-) mice after myocardial ischemia and reperfusion, but significantly activated in the FcR gamma(+/+) mice. CD11b expression on neutrophils was elevated after myocardial ischemia and reperfusion in both mouse groups, whereas myeloperoxidase activity in the injured areas was significantly lower in the FcRgamma(-/-) mice than in the FcRgamma(+/+) mice. These results suggest that the collagen-induced activation of platelets through the FcR gamma plays a pivotal role in the extension of myocardial ischemia-reperfusion injury. FcRgamma and GPVI may be important therapeutic targets for myocardial ischemia-reperfusion injury.