Long-term outcomes of patients with unresectable benign meningioma treated with proton beam therapy.

This study aimed to evaluate the long-term efficacy of proton beam therapy (PBT) for unresectable benign meningiomas at the University of Tsukuba, Japan. From 1986-1998, 10 patients were treated at the Particle Radiation Medical Science Center (PRMSC) with a relative biological effectiveness (RBE) value of 1.0 using an accelerator built for physics experiments. The total dose was compensated with an X-ray in three patients. Following that, from 2002-2017, 17 patients were treated with a RBE value of 1.1 at the Proton Medical Research Center (PMRC) which was built for medical use. At the PRMSC, the total dose ranged from 50.4-66 Gy (median: 54 Gy). During the follow-up, which lasted between 3.8 and 31.6 years (median: 25.1 years), the 5-, 10-, 15-, 20- and 30-year local control rates were 100%, and the 5-, 10-, 15-, 20- and 30-year survival rates were 90, 80, 70, 70 and 36%, respectively. One patient died of brainstem radiation necrosis 5.1 years after PBT. At PMRC, the total dose ranged from 45.0-61.2 GyE, with a median of 50.4 GyE. During the follow-up, which lasted between 3 and 17 years with a median of 10.5 years, the 5-, 10- and 15-year local control rates were 94.1%, and the 5-, 10- and 15-year survival rates were 100, 100 and 88.9%, respectively. Neither malignant transformation nor secondary malignancy was observed, indicating that fractionated PBT may be effective and safely control benign unresectable meningioma even for the lifelong period of time.

Endovascular treatment for mycotic aneurysm using pyoktanin- applied devices.

BACKGROUND: Mycotic thoracic aortic aneurysm is an extremely rare but serious disease because it can easily rupture and has a high mortality rate. The standard therapy for it comprises graft replacement and debridement using systemic antibiotics; nonetheless, this has a high mortality rate and complications. Endovascular aortic repair is considered a bridging therapy before open surgery. However, we have used it at our institution for the radical treatment of mycotic thoracic aortic aneurysm utilizing pyoktanin (methylrosanilide chloride)-applied devices. Thus, the aim of this study was to report our clinical experience with pyoktanin-applied thoracic endovascular aortic repair for the treatment of mycotic thoracic aortic aneurysm, including its effects. METHODS: From April 2017 to July 2019, we performed thoracic endovascular aortic repair using pyoktanin for eight cases of mycotic thoracic aortic aneurysm using Valiant®. During device preparation before insertion, pyoktanin was flushed from the side port instead of saline containing heparin. RESULTS: There were no operative deaths, recurrences of infection, or major complications. Two cases died from pneumonia and cancer; the other six cases were alive during the follow-up period. CONCLUSIONS: Pyoktanin-applied thoracic endovascular aortic repair for mycotic thoracic aortic aneurysm treatment is effective. However, the appropriate use of antibiotics and bundled therapy is necessary at present.

[Emergent Endovascular Treatment of Spontaneous Rupture of the Thoracic Aorta].

Spontaneous rupture of the thoracic aorta is a rare disease with a poor prognosis without obvious trauma, aortic aneurysm and aortic dissection. We report 2 cases of successful endovascular aortic repair for spontaneous rupture of the thoracic aorta. Case 1:A 79-year-old man was referred to our hospital complaining of general fatigue. He returned home without any obvious abnormalities in blood tests and computed tomography (CT). The patient was aware of dizziness and fluttering in the early morning the next day, and was transported to the hospital by shock vital. CT showed rupture of descending aorta, so we performed emergent thoracic endovascular aortic repair (TEVAR). Postoperatively, the patient progressed without paraplegia and was transferred to other hospital on the 15th day of hospital for the purpose of rehabilitation. Case 2:A 87-year-old woman was admitted to hospital with suspected pyelonephritis, but his respiratory status was gradually exacerbated. CT showed a rupture of the thoracic aorta at the distal arch. Ten days ago, CT showed no findings suggestive of aneurysm and dissection at the same site of aorta. We performed emergency TEVAR. She was removed from mechanical ventilation on the 4th postoperative day. We are continuing rehabilitation treatment now.

[Concomitant Atrial Septal Defect Closure and Repair of Pectus Excavatum in a 50-year-old Patient;Report of a Case].

We report a case of atrial septal defect (ASD) with severe pectus excavatum. A 50-year-old female had a stroke due to paradoxical embolism from deep vein thrombosis thorough ASD. Her preoperative computed tomography(CT) revealed a severe pectus excavatum (Haller CT index 28.6). The patient underwent ASD closure and repair of the pectus excavatum concomitantly. Median full sternotomy was performed for ASD closure. And we adopted sterno-costal elevation for pectus excavatum repair. Cartilages of the 3rd to the 7th rib were segmentally resected and the remainders were re-sutured to the sternum. The operation was performed uneventfully. The postoperative echocardiogram revealed no residual shunt. And the deformity of the anterior chest wall was remarkably lessen.

[Persistent cerebral malperfusion following central aortic repair for acute aortic dissection involving the right carotid artery; efficacy of direct carotid artery cannulation].

A 61-year-old man suddenly developed transient left hemiplegia and consciousness disturbance. Computed tomography showed acute Stanford type A aortic dissection. Dissection affected the entire right common carotid artery, and its false lumen extremely compressed the true lumen. The right common carotid artery, along with the right femoral and the left axillary arteries, was used as an inflow of cardiopulmonary bypass during emergency surgery. The ascending aorta that included a large intimal tear was replaced. However, systemic reperfusion either through the femoral artery or through a side branch of vascular prosthesis failed to restore the right cerebral blood flow due to persistent true lumen obstruction by the expanded false lumen in the innominate artery. Therefore, ascending aorta-right carotid artery bypass using that side branch was performed immediately. Though temporary cerebral malperfusion could cause dismal outcome, direct carotid artery cannulation played a key role in this successfully-treated patient.

[Prolactinoma treatment status in the cabergoline era].

The aim of our study is to report the most adequate therapy for prolactinoma in the cabergoline era. From 2003 to 2009, 27 patients with prolactinoma were treated at our hospital. Patients are categorized into 2 groups. The Cabergoline Group: Cabergoline was administered for 5 years and discontinued. Using this protocol, the case with normal prolactin level in addition to having no visible tumor more than 24 months after the discontinuation of cabergoline was judged as cured. The Operation Group: Transsphenoidal surgery (TSS) was performed first. In the Cabergoline group, 12 cases were cured with 5 years cabergoline treatment (Cure) and 6 cases were not cured (Not cure). We compared the pretreatment prolactin level, the normalization of the serum level of prolactin, the degree of invasiveness on MRI, regression of the tumor during treatment on MRI, max dose of cabergoline, degree of pituitary hormone replacement, frequency of pregnancy, and follow up periods between the Cabergoline-cure group, the Cabergoline-not-cure group, and the Operation group. Normalization rate in serum level of prolactin and cure rate were 91% and 63% in the Cabergoline group. Pretreatment prolactine level and the frequency of tumor invasiveness on initial MRI were significantly higher in the Cabergoline-not-cure group compared to the Cabergoline-cure group. All of the five woman accompanied with pregnancy after the treatment belonged to the Cabergoline-cure group. In the Operation group, all 4 cases achieved normalization of serum prolactin level without visible tumor and with normal pituitary function. Cabergoline for prolactinoma is effective, but the cure rate by continuous usage of cabergoline for 5 years was 67%. The factors that cabergoline and / or TSS can cure prolactinoma are non-invasive tumor and prolactin level under 200 ng/mL at pretreatment.

Extremely localized aortic dissection and intussusception of the intimal flap into the left ventricle.

Stanford type A aortic dissection frequently deforms the aortic root and causes aortic regurgitation (AR). On the rare occasion, massive AR can occur due to circumferential intimal disruption and prolapse of the cylinder-shaped intimal flap into the left ventricle. Because of the critical, general, and hemodynamic state of such patients, surgery for this condition carries a high risk. A 62-year-old woman suffered acute chest pain and fell into cardiogenic shock. Computed tomography and transthoracic echocardiography failed to identify the etiology of this rapid hemodynamic collapse. Transesophageal echocardiography (TEE) demonstrated circumferential intimal disruption, 3 centimeters above the aortic valve annulus; a very localized aortic dissection in the proximal ascending aorta; and a to-and-fro motion of cylinder-shaped intima causing severe AR. The dissection did not affect the aorta beyond the intimal tear, and TEE was the only useful modality for the diagnosis. Emergency replacement of the ascending aorta and resuspension of the aortic valve was successfully performed. Residual AR was absent, and the postoperative course was uneventful.

[Refractory pulmonary hypertension following mitral valve repair necessitating percutaneous cardiopulmonary support].

A 37-year-old woman underwent semi-emergency mitral valve plasty for severe mitral regurgitation and congestive heart failure. Although repair was successfully performed and the left ventricular function was maintained, refractory pulmonary hypertension precluded cessation of cardiopulmonary bypass. Inhalation of nitric oxide was ineffective, and assist circulation was required. All data obtained from the Swan-Ganz catheter and other routine monitors were devastating, and the patient showed no clinical recovery in the early postoperative period. However, transesophageal echocardiography (TEE) performed on the 2nd postoperative day (POD) revealed much better filling of the left heart and the patient was weaned from assist circulation on the 4th POD. Pulmonary vascular disease was denied histologically. Late cardiac catheterization disclosed normal pulmonary artery pressure and resistance. TEE played a key role during very complicated postoperative management. Monitoring of the left atrial pressure might be necessary in cases that require assist circulation due to pulmonary vasoconstriction.

[Aortic valve replacement without blood transfusion in a patient with osteogenesis imperfecta].

Osteogenesis imperfecta (OI) is a hereditary systemic connective tissue disorder that is rarely associated with valvular heart diseases. Cardiovascular surgery for patients with OI carries high morbidity and mortality, which mostly results from bleeding tendencies caused by tissue and capillary fragility. We report a 47-year-old male with isolated aortic regurgitation, who underwent aortic valve replacement (AVR) with a mechanical prosthesis without blood transfusion. The perioperative course was uneventful. We believe that a meticulous technique and a planned strategy to avoid every damage to fragile tissues, particularly to bones, are very important during surgery for patients with OI.

Cardiac resurrection after bone-marrow-derived mononuclear cell transplantation during left ventricular assist device support.

We describe a novel therapy of mononuclear cell transplantation combined with a left ventricular assist device (LVAD) for severe ischemic heart failure. Significant myocardial recovery by the LVAD rarely occurs in the severely failing heart. We undertook successful mononuclear cell transplantation in a patient who sustained an acute myocardial infarction that had resulted in the LVAD therapy. The heart regained good function after cell transplantation, and the LVAD was explanted 6 weeks later. These results suggest that this novel therapy could be an alternative to cardiac transplantation for severe ischemic heart failure.

Endovascular stent - graft treatment for blunt aortic injury.

BACKGROUND: Thoracic aortic injury resulting from blunt trauma is usually fatal and almost always associated with multiple, complex, nonaortic injuries that can adversely affect standard surgical repair of the aorta. Endovascular stent - graft treatment offers these patients a less invasive operative treatment option. METHODS AND RESULTS: Between January 2002 and October 2003, 6 patients with blunt aortic injury (BAI) were treated with a stent - graft. In all cases endovascular management was selected because of associated polytrauma or comorbidities. All stent - grafts were homemade and deployed through the femoral artery with 18-20 Fr delivery sheaths. There were no cases of perioperative death, renal failure, or neurologic complication. In one patient the postoperative computed tomography scan showed proximal endoleak requiring additional balloon dilatation and stenting. No other endoleaks were observed by CT in the acute phase. None of the follow-up CT scans revealed evidence of endoleak, migration, or alteration of the stent - graft. CONCLUSIONS: Endovascular repair for BAI is technically feasible and is an alternative to open surgery for high-risk patients.

Simultaneous abdominal aortic aneurysm repair during the on-pump coronary artery bypass grafting.

A case of simultaneous coronary artery bypass grafting (CABG) and abdominal aortic aneurysm (AAA) repair on cardiopulmonary bypass (CPB) is reported. A 74-year-old man was diagnosed with left main coronary disease and infrarenal AAA. Triple CABG and infrarenal AAA repair were performed simultaneously, by different surgeons, on CPB. The duration of CPB, aortic clamp time, and total operation time was 81 min, 33 min, and 245 min, respectively. The patient was extubated three hours after ICU admission and the postoperative course was uneventful. This method is useful for reduction of operation time, for blood salvage, and for adjustment of preload and afterload of the vulnerable heart during AAA repair.