Congenital Abdominal Aortic Aneurysm in a Four Year Old Girl.

INTRODUCTION: Abdominal aortic aneurysm (AAA) in neonates, infants, and children is uncommon, usually occurring as a result of infections, connective tissue disorders, vasculitis, or iatrogenic trauma. A case of idiopathic congenital AAA, an extremely rare disease of unknown origin, is described. REPORT: In March 2018, a 40 mm hypoechoic mass adjacent to the left kidney was detected incidentally by abdominal ultrasound for investigation of hypercalciuria in a four year old girl. Contrast enhanced computed tomography (CT) revealed an infrarenal fusiform AAA measuring 39 mm in maximum diameter, a 15 mm left renal artery aneurysm, a 14 mm right hypogastric artery aneurysm, and a 12 mm left hypogastric artery aneurysm. Cerebral magnetic resonance imaging revealed multiple intracranial aneurysms between 8 and 15 mm in diameter. Considering the size of the AAA and risk of rupture, surgical repair was planned. In May 2018, the congenital AAA was successfully repaired with a 10 mm Dacron aorto-aortic tube graft. Increases in the size of the left renal artery aneurysm and a left middle meningeal artery aneurysm were detected 12 and 14 months post-operatively, respectively. Coil embolisations were performed. An intracranial dural arteriovenous fistula (AVF) was discovered incidentally by cerebral angiography for treatment of the left middle meningeal artery aneurysm. Transarterial embolisation for AVF was also performed. At the 21 month post-operative follow up, the patient is doing well, and the untreated aneurysms have not grown. CONCLUSION: Long term outcomes after surgical repair for congenital AAA are unclear. Moreover, growth of residual aneurysms was detected post-operatively, so follow up with frequent multimodality imaging for multiple aneurysms is necessary.

Effects of M-1, a Major Metabolite of Sarpogrelate, on 5-HT-Induced Constriction of Isolated Human Internal Thoracic Artery.

Sarpogrelate, a selective 5-hydroxytryptamine (5-HT)2A receptor antagonist, inhibits 5-HT-induced platelet aggregation and vasoconstriction. It improves ischemic symptoms in patients with arteriosclerosis obliterans. M-1 is a major metabolite of sarpogrelate, and has been reported to show a higher affinity for the 5-HT2A receptor on platelets than sarpogrelate. However, the effects of M-1 on 5-HT-induced constrictive response in human blood vessels have not been investigated. The internal thoracic artery (ITA) is the key conduit for coronary artery bypass grafting (CABG). 5-HT has been implicated as playing an important role in the pathogenesis of vasospasm. Thus, in the present study, the effects of M-1 on 5-HT-induced vasoconstriction were examined in isolated human endothelium denuded ITA. M-1 inhibited 5-HT-induced vasoconstriction in a concentration-dependent manner. At the highest concentration, M-1 almost completely inhibited the 5-HT-induced vasoconstriction. Expression of 5-HT2A and 5-HT1B receptor proteins in the membrane fraction of ITA smooth muscle cells was confirmed by Western blot analysis. Individually, supramaximal concentrations of sarpogrelate and SB224289, a selective 5-HT1B receptor antagonist, only partially inhibited the 5-HT-induced vasoconstriction. However, simultaneous pretreatment with both these antagonists almost completely inhibited the 5-HT-induced vasoconstriction. The inhibitory effect of M-1 pretreatment mimicked the inhibitory effect of simultaneous pretreatment with sarpogrelate and SB224289. These results suggest that M-1 has antagonistic effects not only on the 5-HT2A receptor but also on the 5-HT1B receptor in human ITA smooth muscle cells. M-1 may be useful as a lead compound for the development of drugs for the treatment of 5-HT-induced vasospasms in CABG.

Extended sandwich technique via the right atrial approach for post-infarction posterior ventricular septal rupture.

An 84-year-old man who underwent percutaneous coronary intervention for acute inferior myocardial infarction due to occlusion of the mid portion of the right coronary artery was transferred to our hospital because of post-infarction posterior ventricular septal rupture. We performed the extended sandwich technique via the right atrial approach as well as tricuspid and mitral valve replacement and permanent pacemaker implantation. Mild residual shunt was detected post-operatively, but the patient's condition was controlled well with diuretics.

Left Subclavian Artery Revascularization for Delayed Paralysis after Thoracic Endovascular Aortic Repair.

Spinal cord ischemia (SCI) is a devastating complication following thoracic endovascular aortic repair (TEVAR). A man with a ruptured thoracic aortic aneurysm (TAA) was transferred to our hospital. Emergency TEVAR, with left subclavian artery (LSA) coverage, was performed for the ruptured TAA. On postoperative day two, the patient had incomplete paralysis in his legs, presumably caused by SCI. We performed LSA revascularization (LSAR) to provide blood supply to the spinal cord; his paralysis improved and almost resolved after surgery. To our knowledge, this is the first report on LSAR's efficacy for delayed paraplegia due to SCI.

Significance of preoperative right ventricular function on mid-term outcomes after surgical ventricular restoration for ischemic cardiomyopathy.

OBJECTIVES: To analyze our surgical experiences with surgical ventricular restoration (SVR) for dilated ischemic cardiomyopathy (ICM) and to determine the significance of preoperative right ventricular (RV) function on outcomes. METHODS AND RESULTS: This study retrospectively analyzed 19 patients who underwent SVR between April 2010 and May 2016. Their mean age and New York Heart Association functional class were 62 ± 11 years and 2.9 ± 0.8, respectively. The preoperative mean left ventricular (LV) end-systolic volume index and LV ejection fraction (LVEF) were 134 ± 56 mL/m2 and 24 ± 7%, respectively. The preoperative mean RV fractional area change (RVFAC) to quantify RV systolic function was 33 ± 13%, as assessed by transthoracic echocardiography. The mean follow-up period was 47 ± 20 months. Three patients died of cardiac causes during the follow-up, with the 3-year and 5-year freedoms from cardiac-related death of 89% and 79%, respectively. Major adverse cardiac events (MACEs) occurred in ten patients, with the 3-year and 5-year MACE-free survival rates of 58% and 41%, respectively. RVFAC (risk ratio [RR] = 0.92, 95% confidence interval [CI] 0.86-0.98, p = 0.01) and LVEF (RR = 0.83, 95% CI 0.68-0.97, p = 0.02) were significant predictors of MACEs in the multivariate analysis. Patients with RVFAC of < 35% had significantly poorer MACE-free survival rates (33% at 3 years) than those with RVFAC of ≥ 35% (80% at 3 years). CONCLUSION: SVR for ICM provided acceptable freedom from cardiac-related death; however, MACEs commonly occurred and was associated with RV dysfunction.

A Giant Cardiac Cavernous Hemangioma Involving the Left Atrial Roof in an Elderly Woman.

Cardiac tumors are relatively rare, with primary hemangiomas being a particularly rare benign neoplasm. Herein, we report a case of a symptomatic cardiac tumor detected via echocardiography in an 82-year-old woman. Although we performed advanced imaging examinations for her heart, we could not diagnose the tumor before surgery. Eventually, a tumor involving the left atrial roof was detected, and it was completely resected to relieve her symptoms and establish a precise diagnosis. Histopathological examination indicated a cardiac cavernous hemangioma. The patient exhibited an uneventful recovery without any complications.

Mid-term results of mitral valve repair for ischemic mitral regurgitation adjusted according to the degree of remodeling progression.

OBJECTIVES: Mitral annuloplasty (MAP) for ischemic mitral regurgitation (IMR) with advanced remodeling is often associated with recurrent mitral regurgitation (MR). We performed surgeries adjusted according to the degree of remodeling; i.e., for advanced remodeling cases, we added subvalvular repair (SVR) to MAP. This study aimed to evaluate our experience with patients with IMR. METHODS AND RESULTS: Thirty patients with IMR (MR grade ≥ 2) were retrospectively analyzed. We performed MAP with SVR for 13 patients (MAP + SVR group) and MAP alone for 17 patients (MAP group). The MAP + SVR group had significantly larger left ventricular dimension and tenting height than the MAP group. Four patients (two in each group) experienced recurrence of MR (MR grade ≥ 2), and the 3-year and 5-year freedom from recurrence of MR rates were 97% and 83%, respectively. Six patients (two in the MAP group and four in the MAP + SVR group) died of cardiac causes during follow-up, and the 3-year and 5-year freedom from cardiac-related death rates were 81% and 74%, respectively. There was no difference between the 2 groups regarding freedom from recurrent MR (p = 0.6) and freedom from cardiac-related death (p = 0.1). The preoperative left ventricular end-systolic dimension was a significant predictor of cardiac death in the multivariate analysis. CONCLUSION: Mitral valve repair adjusted according to the degree of remodeling progression provided durable mitral competence; however, it remains unclear if such a strategy is related to a high probability of freedom from cardiac-related death.

Adventitial cystic disease of the common femoral vein misdiagnosed as deep vein thrombosis.

We report a case of venous adventitial cystic disease of the right common femoral vein, misdiagnosed as deep vein thrombosis before surgery in a 47-year-old woman who presented with swelling and heaviness in her right leg. Complete cyst wall resection and common femoral vein reconstruction via patch angioplasty were performed. The patient's postoperative course was uneventful.

Diabetes Mellitus Induces Hyperreactivity of 5-Hydroxytryptamine (5-HT)-Induced Constriction in Human Internal Thoracic Artery and Is Associated with Increase in the Membrane Protein Level of 5-HT2A Receptor.

Studies indicate that 5-hydroxytryptamine (5-HT) released from activated platelets in coronary artery bypass grafting (CABG) induces 5-HT2A receptor-mediated graft spasm. We previously reported that 5-HT-induced constriction of human endothelium-denuded saphenous vein (SV) was significantly augmented in patients with diabetes mellitus (DM) than in patients without DM (non-DM), without changes in the levels of the membrane-bound 5-HT2A receptor of their smooth muscle cells. Although the internal thoracic artery (ITA) is the key graft conduit for CABG, the effect of DM on the ITA graft spasm is still unclear. Therefore, in this study, we investigated the effect of DM on 5-HT-induced vasoconstriction and the level of membrane-bound 5-HT2A receptor in ITA grafts. 5-HT-induced constriction of the isolated human endothelial-denuded ITA was significantly higher in patients with DM than in patients without DM. In addition, the level of the 5-HT2A receptor in the membrane fraction of human ITA smooth muscle cells was significantly higher in patients with DM than in those without DM. These results demonstrate that DM is a risk factor for CABG in both venous and arterial conduits, and that it differentially affects the level of the membrane-bound 5-HT2A receptor in the venous and arterial smooth muscle cells.

Selection of a Surgical Treatment Approach for Aortic Coarctation in Adolescents and Adults.

PURPOSE: Coarctation of the aorta (CoA) in adolescents and adults is relatively rare. Several operative techniques for CoA in adolescents and adults have been reported, but there is still no consensus. This study aims to highlight the use of individual patient characteristics to select optimal treatment strategies for CoA in adolescents and adults. METHODS: Surgical repair of CoA was performed in five patients (mean age: 34 ± 14 years, range: 13-58 years). All patients had primary CoA, and one had aneurysm above the CoA. One patient had undergone previous aortic valve replacement (AVR) and graft replacement of the ascending aorta. One patient underwent resection of the coarctation without cardiopulmonary bypass (CPB) followed by direct end-to-end anastomosis. Three patients underwent CoA resection with an interposition graft through a lateral thoracotomy with partial CPB. One patient underwent AVR with extra-anatomical bypass (ascending-descending aorta). RESULTS: No in-hospital deaths occurred, and there were no complications. During the follow-up period, there has been no recurrence of CoA. CONCLUSION: CoA in adolescents and adults is associated with different issues from those encountered in infant patients, and comprehensive surgery should be performed in all cases.

Comparison of mitral competence after mitral repair with papillary muscle approximation versus papillary muscle relocation for functional mitral regurgitation.

The purpose of this study was to evaluate the surgical results of papillary muscle approximation (PMA) and papillary muscle relocation (PMR) for functional mitral regurgitation (FMR) and to compare the effects of both procedures on the change in mitral regurgitation (MR) and echocardiogram parameters associated with tethering. Eighteen patients with moderate-to-severe FMR (MR grade ≥2) who underwent PMA or PMR were retrospectively analyzed. Underlying diseases were ischemic cardiomyopathy, idiopathic dilated cardiomyopathy, and aortic valve disease for seven, six, and five patients, respectively. Eleven patients underwent PMA and seven patients underwent PMR. Mitral annuloplasty and surgical ventricular restoration were performed concomitantly for 18 and 6 patients, respectively. None of these patients died in the hospital. Three patients died during the late period; two of these deaths were cardiac related. The rate of 3 years of freedom from cardiac-related death was 89%. After a mean follow-up of 33 months, MR grade was significantly improved compared with preoperative values (3.0 ± 0.8 to 0.7 ± 1.2; p < 0.01). Recurrence of MR grade ≥2 occurred in three patients and the rate of 3 years of freedom from recurrence of MR grade ≥2 was 87%. During follow-up, tenting height (1.1 ± 0.2 to 0.7 ± 0.2 cm; p < 0.01), tenting area (2.2 ± 0.7 to 0.9 ± 0.5 cm2; p < 0.01), and anterior leaflet tethering angle (39° ± 11° to 26° ± 8°; p < 0.01) were significantly improved compared with preoperative values. Posterior leaflet tethering angle significantly deteriorated from 40° ± 7° to 53° ± 15° (p < 0.01); however, it did not further deteriorate compared with the early postoperative value of 55° ± 16° (p = 0.7). There was no difference in echocardiogram parameters associated with tethering between PMA and PMR throughout the observation period. Both methods were associated with lasting relief of MR and reverse left ventricular remodeling. There was no difference between PMA and PMR regarding the effect on mitral valve competence. Both methods allowed durable mitral repair and good clinical outcomes.

Accompanying role of hepato-biliary-pancreas surgeon in urological surgery.

INTRODUCTION: The present case reports demonstrated the accompanying surgical support from hepato-biliary-pancreas (HBP) surgeons for urological surgery to secure operative safety because HBP surgeons are well experienced in dissecting techniques for mobilization of the liver or pancreas. We experienced 9 consecutive patients who underwent nephrectomy, adrenectomy or resection of retroperitoneal tumors by urological surgeons. Cardiovascular intervention was also required in cases of long tumor thrombus into the vena cava. CASES: All patients had no severe co-existing diseases except the main tumor. Reverse T-shape incision was performed in 7 cases and thoracolaparotomy in two. Dissection and mobilization at the site of severe compression by the urinary tumors were performed in three cases. Partial liver resection was performed for testicular liver metastases in two, and right hepatectomy for right renal cancer was performed in one. Encircling the vena cava and preparation of transection for tumor thrombi were performed in three, and among these, cardiovascular intervention was necessary in two because of extension into the right atrium. During admission, all patient outcomes were uneventful without severe complications. We herein showed the representative two cases of combined surgery. DISCUSSION: and conclusion The point of this case report is the coordination between each surgeon and anesthesiologist under precise perioperative planning or management. The role of HBP surgeons is to provide information as a specialist on the operative field for urological or cardiovascular surgery to achieve operative safety.

Successful Embolization Therapy through Reentry Tear in the Right Subclavian Artery for Treating Patent False Lumen in the Aortic Arch Formed after Type A Dissection Repair.

A 73-year-old woman had undergone hemiarch replacement with primary entry resection for treating acute type A dissection 6 years ago. Postoperative computed tomography (CT) showed a patent false lumen (FL) in the aortic arch and a reentry tear in the right subclavian artery. The remaining aortic arch enlarged, which resulted in formation of a 55-mm-diameter aneurysm. We performed reentry occlusion using embolization with glue and coil. The patient's clinical course after the procedure was uneventful, and subsequent CT showed that FL was thrombosed and had decreased in size.

Effect of preoperative left ventricular diastolic dysfunction on mid-term outcomes after surgical ventricular restoration for ischemic cardiomyopathy.

OBJECTIVES: The impact of surgical ventricular restoration (SVR) on survival and major adverse cardiac events (MACEs) is still controversial. The purposes of this study were to analyze our surgical experience with SVR for ischemic cardiomyopathy and to determine the effect of preoperative left ventricular diastolic dysfunction on mid-term outcomes after SVR. METHODS AND RESULTS: Between April 2010 and May 2016, 19 patients underwent SVR. The mean age was 60 ± 11 years and the mean New York Heart Association functional class was 2.9 ± 0.8. Preoperative mean left ventricular end systolic volume index (LVESVI) and ejection fraction (LVEF) were 134 ± 56 mL/m2 and 24 ± 7%, respectively. The early-to-late mitral valve flow ratio (E/A) on echocardiogram was 2.4 ± 1.8 and 9 patients had E/A ≥2, excluding 2 patients with atrial fibrillation. The mean follow-up period was 29 ± 16 months. One patient died of heart failure at 6 months postoperative; the overall survival rate at 3 years was 95%. MACEs requiring hospitalization occurred in 10 patients; E/A ≥2, or restrictive filling pattern, was the only significant predictor of MACE in multivariate analysis. Reverse remodeling was associated with E/A <2, but not E/A ≥2. There was also a significant difference between patients with E/A <2 vs. ≥2 with respect to MACE-free survival rates at 3 years (100 vs. 10%; p = 0.001). CONCLUSION: The degree of preoperative diastolic dysfunction can influence the outcome after SVR. Patients with E/A ≥2 may not be good candidates for SVR.

Aortic Pseudoaneurysm due to Simple Vertebral Compression Fracture Treated with Conservative Management.

Blunt aortic injures are rarely associated with minimal trauma. We present a 78-year-old man with an aortic pseudoaneurysm resulting from a simple vertebral compression fracture, which was conservatively managed. He was diagnosed with a compression fracture from a minor fall 10 days previously, and fortuitously he visited the hospital after which follow-up computed tomography (CT) for previous multiple aortic surgeries was performed. The enhanced CT revealed a pseudoaneurysm on the abdominal aorta, which was bleeding from a pinhole perforation. He was conservatively treated and follow-up CT 9 months later revealed that the pseudoaneurysm had disappeared.

Clinical Implications of Additional Pedal Artery Angioplasty in Critical Limb Ischemia Patients With Infrapopliteal and Pedal Artery Disease.

PURPOSE: To evaluate the clinical implications of additional pedal artery angioplasty (PAA) for patients with critical limb ischemia (CLI). METHODS: Twenty-nine patients (mean age 77.8±8.6 years; 21 men) with CLI (32 limbs) presenting with de novo infrapopliteal and pedal artery (Kawarada type 2/3) disease were reviewed. The need for PAA was based on the existence of sufficient wound blush (WB) around the target wounds after conventional above-the-ankle revascularization. Fourteen patients with insufficient WB in 14 limbs received additional PAA, while 15 patients with sufficient WB in 18 limbs did not. The groups were compared for overall survival, limb salvage, and amputation-free survival within 1 year after the procedure. The wound healing rate, time to wound healing, and freedom from reintervention rate were also evaluated. RESULT: The success rate of additional PAA was 93% (13/14). All limbs with successful PAA achieved sufficient WB (13/13). Despite insufficient WB before the additional PAA, overall survival (86% vs 73%, p=0.350), limb salvage (93% vs 83%, p=0.400), amputation-free survival (79% vs 53%, p=0.102), and freedom from reintervention (64% vs 73%, p=0.668) rates were similar in both groups. Furthermore, the wound healing rate (93% vs 60%, p=0.05) was higher and time to wound healing (86.0±18.7 vs 152.0±60.2 days, p=0.05) was shorter in the patients who received PAA. CONCLUSION: Additional PAA might improve the WB and clinical outcomes (especially speed and extent of wound healing) in patients with CLI attributed to infrapopliteal and pedal artery disease.

Angiotensin II, as well as 5-hydroxytriptamine, is a potent vasospasm inducer of saphenous vein graft for coronary artery bypass grafting in patients with diabetes mellitus.

Diabetes mellitus (DM) is an important risk factor for adverse outcomes of coronary artery bypass grafting. The bypass grafts harvested from patients with DM tend to go into spasm after their implantation into the coronary circulation. To clarify the contribution of 5-hydroxytriptamine (5-HT) and angiotensin II (AngII) in the bypass graft spasm, we examined the contractile reactivity to 5-HT or AngII of isolated human endothelium-denuded saphenous vein (SV) harvested from DM and non-DM patients. The 5-HT-induced constriction of the SV was significantly augmented in the DM group than in the non-DM group, which is similar to our previous report. AngII-induced constriction of the SV was also significantly augmented in the DM group than the non-DM group. Especially in the non-DM group, the AngII-induced maximal vasoconstriction was markedly lower than the 5-HT-induced one. Meanwhile, the increasing rates of AngII-induced vasoconstriction in the DM group to the non-DM group were significantly greater than those of 5-HT-induced vasoconstriction. These results indicate that 5-HT is a potent inducer of SV graft spasm in both DM and non-DM patients, while AngII is a potent inducer of SV graft spasm only in patients with DM. Furthermore, the protein level of AngII AT1 receptor (AT1R), but not the protein level of 5-HT2A receptor, in the membrane fraction of the SV smooth muscle cells of DM patients was significantly increased as compared with that of the non-DM patients. These results suggest that the mechanism for hyperreactivity to AngII in the SV from DM patients is due to, at least in part, the increase in the amount of AT1R on membrane of the SV smooth muscle cells.

[Mitral Valve Replacement with a Low-Profile Bioprosthesis in Combination with Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy;Report of a Case].

An 83-year-old woman diagnosed with hypertrophic obstructive cardiomyopathy was referred to our hospital. Her echocardiogram revealed diffuse left ventricular hypertrophy, severe mitral valve regurgitation with systolic anterior motion of the mitral valve, and left ventricular obstruction with a peak outflow gradient of 142 mmHg. Cardiac catheterization revealed a peak pressure gradient of 60 mmHg across the left ventricular outflow tract. Because of the patient's advanced age, as well as uncertainty regarding our ability to resolve her mitral regurgitation, we performed mitral valve replacement with a St. Jude Medical Epic porcine low-profile bioprosthesis in combination with septal myectomy. The patient's postoperative course was uneventful. At 1 year after the operation, her functional status was New York Heart Association class I. The echocardiogram showed the peak outflow gradient markedly decreased to 9 mmHg.

A new method for the adjustment of neochordal length: the adjustable slip knot technique.

The use of expanded polytetrafluoroethylene (ePTFE) sutures for the correction of mitral valve prolapse has become a standardized procedure. Adjustment of neochordal length is crucial to the efficacy of this technique. Various methods have been described for this purpose; however, the fine adjustment of neochordal length is technically challenging. We describe a simple and effective technique for the implantation of neochordae, which we have termed the 'adjustable slip knot technique'. The first step of this technique is reinforcement of the papillary muscle by a Teflon pledget with or without polytetrafluoroethylene (CV-4) loops. The second step is the formation of a neochordal loop by introducing an ePTFE suture between the affected mitral leaflet and the papillary muscle or ePTFE loops. The third step is the adjustment of the length of neochordae. The formation of a slip knot in one arm of the ePTFE suture is the pivot of this technique. The neochordal loop can be constricted by the application of tension to one arm of the suture. We applied this technique in 5 patients with satisfactory results.

Water-soluble jack-knife prawn extract inhibits 5-hydroxytryptamine-induced vasoconstriction and platelet aggregation in humans.

Coronary artery spasm plays an important role in the pathogenesis of various ischemic heart diseases or serious arrhythmia. The aim of this study is to look for functional foods which have physiologically active substances preventing 5-hydroxytryptamine (5-HT)-related vasospastic diseases including peri- and postoperative ischemic complications of coronary artery bypass grafting (CABG) from ocean resources in Japanese coastal waters. First, we evaluated the effect of water-soluble ocean resource extracts on the response to 5-HT in HEK293 cells which have forcibly expressed cyan fluorescent protein-fused 5-HT2A receptors (5-HT2A-CFP). Among 5 different water-soluble extracts of ocean resources, the crude water-soluble jack-knife prawn extract (WJPE) significantly reduced maximal Ca(2+) influx induced by 0.1 µM 5-HT in a concentration-dependent manner. The Crude WJPE significantly inhibited, in a concentration-dependent manner, 5-HT-induced constriction of human saphenous vein. 5-HT released from activated platelets plays a crucial roles in the constriction of coronary artery. Next the WJPE was purified for applying the experiment of 5-HT-induced human platelet aggregation. The purified WJPE significantly inhibited 5-HT-induced human platelet aggregation also in a concentration-dependent manner. Based on our findings, jack-knife prawn could be one of a functional food with health-promoting benefits for most people with vasospastic diseases including patients who have gone CABG.