Is central repair with coronary artery bypass grafting enough for multi-organ malperfusion in acute type A aortic dissection with coronary malperfusion?

OBJECTIVES: Acute type A aortic dissection with coronary malperfusion syndrome is rare but associated with high mortality. Multi-organ malperfusion is an independent predictor of acute type A aortic dissection. Coronary malperfusion requires treatment, but it is not feasible to treat all malperfusions. The adequacy of "central repair and coronary artery bypass grafting" for patients with coronary and other organ malperfusion is unknown. METHODS: Of the 299 patients who underwent surgery between 2008 and 2018, 21 patients with coronary malperfusion, who received cental repair with coronary artery graft bypass, were analyzed retrospectively. They were divided; into Group M (n = 13, coronary and other organ malperfusion) and Group O (n = 8, coronary malperfusion only). The patient background, surgical content, details of malperfusion, surgical mortality and morbidity, and long-term outcome were compared. RESULTS: There was no difference in operation time (205 ± 30 vs. 266 ± 88, p = 0.49), but the time from arrival to circulatory arrest tended to be shorter in Group M (81 vs. 134, p = 0.05). Among Group M, cerebral malperfusion was the most common at 92%. Two of the three cases with mesenteric malperfusion died. The mortality of Group M and Group O was 13% and 15% (P = 0.85), respectively. There was no difference in long-term mortality (p = 0.62). CONCLUSIONS: Central repair and coronary artery bypass grafting is a sufficiently acceptable treatment for patients with acute type A aortic dissection and multi-organ malperfusion, including coronary malperfusion.

[Ascending Aortic Replacement and Aortic Valve Replacement in a Patient with Cold Agglutinins].

Cold agglutinins are commonly found in healthy individuals. Cold agglutinins bind to red blood cells at low temperatures, such as during cardiovascular surgery. Agglutination leads to hemolysis and embolism. A 73-year-old man with cold agglutinins disease underwent ascending aortic replacement and aortic valve replacement. As there was no agglutination reaction at 34 degrees centigrade in preoperative testing, we performed the operation under cardiopulmonary bypass and cardioplegia at a temperature above 34 degrees centigrade. He was discharged without any complications.

Psoas muscle size, possible sarcopenia and frailty, and long-term survival in elderly patients after isolated surgical aortic valve replacement for aortic stenosis.

PURPOSE: This study investigated the use of psoas muscle area index (PAI) as an indicator of mortality risk in relation to survival in elderly patients after isolated surgical aortic valve replacement (SAVR) for aortic valve stenosis (AS). METHODS: Between January 2005 and March 2015, 140 patients with AS, aged ≥ 70 years, and with preoperative abdominal computed tomography scans, underwent elective, primary, isolated SAVR. PAI showed the ratio of the psoas muscle cross-sectional area at the fourth lumbar vertebral level to body surface area, and PAI less than the gender-specific lowest 20th percentile we called "low PAI" for the purposes of this study. Patients were classified as low PAI (n = 29) or normal PAI (n = 111). RESULTS: The mean age in the low-PAI group was significantly older than in the normal-PAI group (81.0 vs. 77.3 years; p = 0.001). The mean follow-up was 4.25 years. The low-PAI group had a lower survival rate than the normal-PAI group at 1 year (89.7 ± 5.7% vs. 96.3 ± 1.8%), at 3 years (71.6 ± 9.3% vs. 91.5 ± 2.7%), and overall (53.0 ± 13.4% vs. 76.0 ± 5.6%; p = 0.039). The prognostic factors of mortality included low PAI (hazard ratio 2.95; 95% confidence interval 1.084-8.079; p = 0.034). CONCLUSIONS: PAI was associated with reduced overall survival after isolated SAVR in elderly people. PAI measurement may help to predict patient risks.

Infected Aortic Aneurysm Caused by Streptococcus zooepidemicus: A Case Report and Literature Review.

A 66-year-old Japanese male working at a stable developed abdominal pain and fever and was brought to the emergency department. The computed tomography scan revealed an aneurysm of approximately 70 mm in diameter, with an irregular border, at the infrarenal abdominal aorta. Emergency surgery was performed with a bifurcated Dacron graft. Streptococcus zooepidemicus was observed on the aneurysm wall. He was discharged in good condition and was prescribed oral amoxicillin/clavulanic acid for 4 months. He has remained well and did not develop inflammation. Evaluation of patient history and data, including the consumption of unpasteurized dairy food, occupation, and direct contact with animals, is important for an early diagnosis, a prompt surgery, and an appropriate antibiotic therapy.

Cardiac Surgery Using Hypothermic Circulatory Arrest in a Case of Essential Thrombocythemia.

We present the case of a 61-year-old patient with a history of essential thrombocythemia (ET) who was diagnosed as having aortic valve stenosis and dilatation of his ascending aorta. His aortic valve and ascending aorta were replaced under hypothermic circulatory arrest (HCA). No clear guideline exists for preoperative, perioperative, and postoperative management of cardiac surgery using HCA for ET patients. After performing risk assessment, we prescribed preoperative aspirin therapy and postoperative care was planned as usual for cardiovascular surgery in our establishment. Unexpectedly, activated clotting time did not exceed 400 seconds, but the course of treatment was otherwise uneventful.

Outcomes after aortic valve replacement for aortic valve stenosis, with or without concomitant coronary artery bypass grafting.

OBJECTIVES: To assess the effects of concomitant coronary artery bypass grafting (CABG), we analyzed the outcomes after aortic valve replacement (AVR) for aortic stenosis (AS) with and without coronary artery bypass grafting (CABG) at our institution. METHODS: Between 2002 and 2014, 605 consecutive patients underwent AVR for AS. Of these, the 275 who received isolated AVR (Group A) and the 122 who received both AVR and CABG (Group AC) patients were enrolled, after the exclusion of 8 patients who underwent reoperation and 200 who received other concomitant surgery. AVR and all bypass anastomoses were performed under intermittent retrograde cold blood cardioplegia. Multivariate analysis was used to assess any association of concomitant CABG with morbidity and mortality. Kaplan-Meier analysis was used to assess all-cause mortality. RESULTS: No significant difference in 30-day mortality was found between Group A and Group AC (1.5% vs. 0.8%, P = 1.000). Nor did post-discharge survival differ significantly between the two groups (P = 0.20). Likewise, multivariate analysis showed that concomitant CABG was not associated with significantly greater in-hospital or mid-term mortality. Operative morbidities were comparable between the two groups, in terms of stroke (1.8% vs. 3.3%, P = 0.466), prolonged ventilation (4.0% vs. 5.5%, P = 0.565), deep sternal infection (1.8% vs. 3.3%, P = 0.466), and acute renal failure (0.4% vs. 1.6% P = 0.176). CONCLUSIONS: Concomitant CABG at the time of AVR was performed without increasing early- or mid-term mortality. This absence of increased risk deserves consideration when choosing between different treatment strategies.

[Cor Triatriatum in an Adult Patient Conbined with Mitral Regurgitation and Coronary Artery Disease;Report of a Case].

A 71-year-old female, who had been diagnosed with cor triatriatum 30 years before, presented with complains of worsening dyspnea and fatigue. She was diagnosed with a combination of cor triatriatum, mitral valve disease and coronary artery disease. She underwent removal of the left atrial membrane, repair of the mitral valve and coronary artery bypass grafting. This combination of cor triatriatum, mitral valve disease and coronary artery disease is exceedingly rare. She remains well at 3 years' follow-up.

Immunochromatography test for rapid diagnosis of Mycoplasma pneumoniae infection.

The sensitivity and specificity of a new rapid Mycoplasma pneumoniae antigen immunochromatography (IC) test, DK-MP-001, were determined using particle agglutination (PA) antibody response and loop-mediated isothermal amplification (LAMP) gene detection as the gold standard. Of 165 patients, 59 were diagnosed with M. pneumoniae infection based on a ≥fourfold rise of serum PA antibody during the course of the illness. Of the first visit swabs, 60 were positive for M. pneumoniae on LAMP, and 49 were positive for M. pneumoniae antigen on IC test. Compared with PA antibody and LAMP, the sensitivity/specificity of the IC test were 81.4% (48/59) and 99.1% (105/106); and 81.7% (49/60) and 100% (105/105), respectively. IC test detected antigen in pharyngeal swabs more sensitively than in nasal swabs for the same subjects (P < 0.05). The IC test performs well enough to be used with pharyngeal swabs at the first examination.

Etiology and clinical study of community-acquired pneumonia in 157 hospitalized children.

We tried to verify whether the currently employed diagnosis and treatment of community-acquired pneumonia in children were appropriate. For this purpose, we created tentative criteria for the classification of pediatric community-acquired pneumonia. We classified the community-acquired pneumonia into ten categories: (1) bacterial, (2) concomitant viral-bacterial, (3) viral, (4) mycoplasmal, (5) concomitant mycoplasmal-bacterial, (6) concomitant mycoplasmal-viral, (7) chlamydial, (8) concomitant chlamydial-bacterial, (9) concomitant chlamydial-viral, and (10) unknown. Children aged 1 month to 13 years with radiographic and clinical evidence of pneumonia were enrolled. Between October 2001 and September 2002, we enrolled 165 patients. The etiologic agents were determined in 126 of the 157 (80.3%) patients who were finally diagnosed with pneumonia. Two blood cultures were positive for Haemophilus influenzae type b and Streptococcus pneumoniae. A viral infection alone was found in 28 of the 157 patients (17.8%), a bacterial (without mycoplasmal) alone infection in 42 (26.8%), a concomitant viral-bacterial infection in 28 (17.8%), and a mycoplasmal infection in 27 (17.2%) patients. RS virus was identified in 28 patients (17.8%), influenza A in 12 (7.6%), parainfluenza 3 in 8 (5.1%), adenovirus in 8 (5.1%), and influenza B and measles virus in 1 patient each. Streptococcus pneumoniae was the most common cause of bacterial pneumonia. We chose the initial treatment according to clinical and laboratory findings on admission (i.e., patients' age, clinical course, chest X-ray, and laboratory findings). In 68 of the 71 patients with bacterial (without mycoplasmal) pneumonia, an appropriate antibacterial-agent was prescribed. In 25 of the 27 patients with mycoplasmal pneumonia, clindamycin and minocycline were prescribed.

Human macrophage metalloelastase worsens the prognosis of pancreatic cancer.

OBJECTIVE: To evaluate the role of human macrophage metalloelastase (HME) in pancreatic cancer. SUMMARY BACKGROUND DATA: HME, a member of the human matrix metalloproteinase family, possesses elastolytic activity and is critical for the degradation of extracellular matrix proteins. Inasmuch as tumor invasion and metastasis formation require lysis of extracellular matrix, HME plays a critical role in both processes. METHODS: HME expression was analyzed by Northern blot analysis, reverse transcriptase-polymerase chain reaction, Western blot analysis, and immunohistochemistry in 39 pancreatic cancer tissues and 13 normal controls. The molecular data were related to clinicopathologic parameters and patient survival. RESULTS: In human pancreatic cancer, overexpression of HME mRNA was present in 25 of 39 pancreatic cancer tissues (64%) and in five pancreatic cancer cell lines. In contrast, low levels of HME mRNA expression were present in 13 normal pancreatic tissues samples. By Western blot analysis, high levels of HME were found in pancreatic cancer tissues and in the pancreatic cancer cell lines compared with the normal controls. Fifty-six percent of the cancer samples exhibited HME immunoreactivity in the cancer cells, and 63% in the stromal cells. Analysis of the survival data revealed that patients whose tumors exhibited HME mRNA overexpression lived significantly shorter compared with patients whose tumors did not overexpress HME. No relationship between HME expression and tumor stage, tumor grading, or presence of lymph node metastases was found. CONCLUSIONS: These findings indicate that HME participates in pancreatic cancer progression and that its presence worsens the prognosis. These data suggest a benefit of its inhibition in the treatment of pancreatic cancer.

Accumulation of anthranilic acid and N-glucosylanthranilic acid by a Corynebacterium glutamicum mutant resistant to DL-serine hydroxamate.

During a study on the effect of DL-serine hydroxamate on Corynebacterium glutamicum (JCM1318, a wild strain), a mutant resistant to the drug, strain TO3002, was isolated. This mutant accumulated five Ehrlich's reagent positive fluorescent substances in the culture medium. Two major and one minor fluorescent products were isolated by preparative high-performance liquid chromatography following charcoal column chromatography from the culture supernatant. One major product was identified as anthranilic acid whose molecular ion was confirmed to be 137 by a measurement of liquid chromatography-mass spectrometry (LC-MS), and NMR spectrum coincided with that of anthranilic acid. LC-MS spectra of another major and the minor product showed that they had the same molecular weight of 299. This major product was supported to be N-glucosylanthranilic acid (N-o-carboxyphenyl-1-beta-glucosylamine) by two-dimensional (1)H and (13)C NMR analyses. The minor product was speculated to be an Amadori compound derived from N-glucosylanthranilic acid. N-Glucosylanthranilic acid accumulated in the early phase, then decreased in the late phase of the culture. In contrast, the accumulation of anthranilic acid increased remarkably in the late phase of the fermentation. Based on this phenomenon, it was assumed that N-glucosylanthranilic acid once accumulated was decomposed to form anthranilic acid, at least in large part, with the progress of fermentation. The strain TO3002 showed a leaky requirement for L-tryptophan or indole (but did not for anthranilic acid) and resistance to DL-serine hydroxamate.