[A Thrombus in the Right Atrium Associated with Pyogenic Liver Abscess].

Hepatic abscesses are divided into bacterial and amoebic types. Although the prognosis of bacterial liver abscesses has improved owing to progress in drainage techniques and antimicrobial agents, poor outcomes remain common. While there have been some reports of amoebic liver abscesses complicated by thrombosis, bacterial liver abscesses and subsequent thrombus in the right atrium are very rare. We herein report the case of an 82-year-old man. He had suffered acute obstructive suppurative cholangitis 10 months previously, and bile culture yielded Enterococcus faecalis. In the present case, a right atrial thrombus caused by a bacterial liver abscess was observed and the causative organism was thought to be Enterococcus faecalis, for which was detected in a blood culture was positive. The patient was successfully treated with hepatic abscess drainage and surgical right atrial thrombectomy under cardiopulmonary bypass with a beating heart.

[Acute Pulmonary Thromboembolism with Chiari Network:Report of a Case].

A 60-year-old woman was admitted to our hospital for dyspnea. Contrast-enhanced computed tomography( CT) revealed acute pulmonary artery thromboembolism. An echocardiogram showed a movable structure in the right atrium. Emergency surgery was performed under general anesthesia. The movable structure in the right atrium looked like a Chiari network with a diameter of over 5 cm, and no obvious thrombus was found. The patient had a good postoperative course and was discharged home on postoperative day 17. The Chiari network is a remnant structure of the fetal venous sinus valve, and its diagnosis was important for determining the appropriate treatment plan for this case.

Effect of Noncompacted Myocardial Resection on Isolated Left Ventricular Noncompaction.

Isolated left ventricular noncompaction, where broad trabeculae and deep intertrabecular recesses are observed in the left ventricular myocardium resulting from an arrest in normal embryogenesis, is a rare cardiomyopathy. We present a report on isolated trabeculectomy and postoperative echocardiographic follow-up showing recovery of cardiac function for isolated left ventricular noncompaction.

Placement of a Zenith® Dissection Endovascular System in the Descending Thoracic Aorta Can Hamper Further Surgical Aortic Operations.

INTRODUCTION: The efficacy of endovascular treatment for complicated Stanford type B acute aortic dissection is being established. However, aortic events sometimes occur, and some cases require surgical intervention. REPORT: A 52 year old man underwent ascending aorta replacement for Stanford type A acute aortic dissection in August 2016. Post-operative computed tomography (CT) showed residual dissection from the aortic arch to the right common iliac artery and a large re-entry in the right common iliac artery (RCIA). Two months after the operation, CT revealed enlargement of the false lumen of the thoracic aorta and the thoracic aortic diameter. Aiming to reduce the false lumen and remodel the aorta, a three stage operation was performed, as described below. Four months after the dissection, total aortic arch replacement and a frozen elephant trunk insertion were performed as the first stage. Subsequently, as a second stage operation, thoracic endovascular repair (TEVAR) was performed using a Zenith® Dissection Endovascular System (Cook Japan Co., Ltd, Tokyo, Japan), with the aim of expanding the true aortic lumen. The implanted devices were a stent graft for the proximal part and two bare stents for the middle and distal part. As a third stage operation, abdominal aortic endovascular treatment was performed with the purpose of closing the re-entry from the RCIA. However, two years after the three stage operation, CT showed that the thoracic aorta was over 60 mm in diameter. Graft replacement of the thoraco-abdominal aorta was performed. The bare stents were expected to be easily removable from the aorta, but unexpectedly, they were strongly attached to the intima, which made it extremely difficult to perform surgical and aortic operations. DISCUSSION: Surgical operations for the aorta can become more difficult after bare stent placement in the aorta.

Adult-onset primary Ewing's sarcoma of the right atrium: a case report.

BACKGROUND: Primary cardiac tumors, which are only detected in 0.001-0.03% of autopsies, are rare. Only 25% of primary cardiac tumors are malignant, of which 95% are sarcomas. Ewing's sarcoma, one of the Ewing's sarcoma of family tumors, is thought to be derived from neural crest cells. While Ewing's sarcoma usually presents in the bone of children, Ewing's sarcoma of cardiac origin is rare, with only a few reports described in the literature. The prognosis is unpredictable because of the scarcity and unestablished treatment. We herein report an extremely rare case of primary cardiac Ewing's sarcoma in the right atrium of a 64-year-old man. CASE PRESENTATION: The patient is a 64-year-old Japanese male who was referred to our hospital to treat a floating mass of the right atrium (RA). Although the patient was asymptomatic, we performed an operation to urgently resect the floating mass on the next day of admission due to the risk of pulmonary embolism. The operation was performed under cardiopulmonary bypass and cardiac arrest. We resected the tumor with at least 1.5 cm of the RA wall as a margin. The postoperative pathological diagnosis of the mass was compatible with a primitive neuroectodermal tumor (PNET, a form of Ewing's sarcoma). The cells were positive for CD56, CD99, and Vimentin and negative for S-100 and Desmin. Although no malignant cells were observed in the margin of the resected RA wall and the sarcoma was completely resected, he was transferred to another hospital to receive adjuvant postoperative chemotherapy to improve the prognosis by preventing subclinical micrometastasis. CONCLUSIONS: We experienced an extremely rare case of primary cardiac Ewing's sarcoma in the right atrium of a 64-year-old man, which was successfully resected under cardiac arrest. Although the sarcoma was completely resected, postoperative chemotherapy and long-term follow-up are recommended for patients with primary cardiac sarcoma because of the high rates of metastasis and recurrence.

Early and mid-term outcomes of total arch replacement with the frozen elephant trunk technique for type A acute aortic dissection.

OBJECTIVES: The aim of this study was to evaluate the outcomes of the frozen elephant trunk (FET) technique, using the J Graft FROZENIX for Stanford type A acute aortic dissection, in comparison with the unfrozen elephant trunk technique. METHODS: Between January 2010 and August 2018, we performed total arch replacement for Stanford type A acute aortic dissection in our hospital. Thirty patients were treated by the elephant trunk procedure (ET group), and 20 patients were treated by the FET procedure (FET group). To evaluate aortic remodelling, we measured the area of the aorta, the true lumen and the false lumen at 12 months of follow-up. RESULTS: Preoperative characteristics and operation time were not significantly different between the 2 groups. The quantity of blood transfused was much greater in the ET group than in the FET group. Resection or closure of the most proximal entry tear was obtained in 73.3% (22 out of 30 patients) in the ET group and 100% (20 out of 20 patients) in the FET group (P = 0.015). There was no case that had recurrent nerve palsy or paraplegia in the FET group. Stent graft-induced new entry occurred in 3 cases (15.8%) in the FET group. There were no significant differences between the 2 groups in aortic area, true lumen area or false lumen area. CONCLUSIONS: Total arch replacement with the FET technique in Stanford type A acute aortic dissection carries a risk of distinct complications; however, with thorough advance planning, it should be possible to safely institute this treatment. Further randomization, with a comparison of each technique, is required to provide clear conclusions whether the FET is useful for acute Stanford type A aortic dissection.

Acute Dissection of the Middle Colic Artery Immediately after Endovascular Abdominal Aortic Aneurysm Repair: A Case Report.

A 78-year-old man underwent endovascular abdominal aortic aneurysm repair (EVAR) for a true aortic aneurysm. He developed sudden abdominal pain 4 hr after EVAR. Angiography revealed a dissected aneurysm of the middle colic artery (MCA). Despite conservative treatment, follow-up computed tomography revealed an expanded aneurysm of the MCA. We therefore performed coil embolization of the dissected MCA to prevent a rupture of the aneurysm. There has never been a reported case of acute dissection of the MCA immediately after EVAR that was not caused by catheters. In this report, we discuss the possible underlying mechanisms and the optimal therapeutic strategy for this rare complication.

Aortic valve replacement and tricuspid valve annuloplasty via a left thoracotomy in an adult with left pulmonary agenesis.

We report a case of a 66-year-old man who was diagnosed with severe aortic regurgitation, moderate tricuspid regurgitation and chronic atrial fibrillation. Preoperative computed tomography showed left lung agenesis. We performed aortic valve replacement, tricuspid valve annuloplasty and right pulmonary vein isolation via a left thoracotomy. This approach provided an adequate field of view.

[Aortic Valve Replacement after Balloon Valvuloplasty for Aortic Valve Stenosis in a Dialysis Patient with Cardiogenic Shock;Report of a Case].

A 67-year-old man on chronic hemodialysis was admitted with worsening congestive heart failure due to critical aortic stenosis. Echocardiography showed severe aortic stenosis with a valve area of 0.67 cm2 and an ejection fraction of 0.31. Cardiac catheterization revealed severe pulmonary hypertension with pulmonary artery pressures of 62/32 mmHg. In the middle of cardiac catheterization, the systolic pressure declined to 60 mmHg due to cardiogenic shock. Dopamine hydrochloride and dobutamine hydrochloride infusions were necessary to maintain a systolic pressure greater than 80 mmHg. Balloon aortic valvuloplasty was urgently performed. The patient's symptoms rapidly resolved except for angina on exertion. One month later, elective aortic valve replacement was performed. The postoperative course was uneventful and the he was discharged on the 60th postoperative day. A follow-up echocardiogram 6 months postoperatively revealed normal prosthetic valve function and an ejection fraction of 0.6.

[Total arch replacement using a new sheathless open stent-grafting technique].

Total arch replacement for extended distal arch aneurysm has been known to have a poor outcome because of a limited view on the distal side. An open stent-grafting technique has been employed in many institutions, but several complications have been reported. Specifically, embolism of the distal artery from aneurysm debris and injury to the aortic wall are serious complications. Therefore, we have developed and tested a new sheathless stent-grafting system. We use a small-sized sheath (12 Fr) as an inner cylinder and a stainless-steel Z-shaped stent (Gianturco:William Cook Europe A/S) in the distal part of the graft. This system is deployed by releasing 3-0 polypropylene suture after inserting the full-length graft. The major advantages of this system, compared with other devices, include flexibility, less invasiveness to the aortic wall and low potential for graft migration. This new system may be feasible and clinically effective in the surgical treatment of extended distal arch aneurysm.

Angiotensin II type I receptor blockade suppresses glomerular renin-angiotensin system activation, oxidative stress, and progressive glomerular injury in rat anti-glomerular basement membrane glomerulonephritis.

Excessive renin-angiotensin system (RAS) activation within the kidney induces not only renal oxidative stress but also renal scarring and dysfunction. This study examined the effects of an angiotensin II (Ang II) type I receptor (AT1R) blocker (ARB) on the progression of renal injury in rat anti-glomerular basement membrane glomerulonephritis (GN), with a particular focus on the participation of glomerular RAS activation in glomerular structural alterations, inflammation, and oxidative stress. Nephritic rats were divided into 2 groups and treated with vehicle or ARB until day 28. Treatment with ARB improved proteinuria significantly in nephritic rats. Vehicle-treated nephritic rats developed crescentic GN accompanied by marked macrophage infiltration and the enhanced expression of glomerular α-smooth muscle actin (α-SMA), angiotensinogen (AGT), Ang II, AT1R, and NADPH oxidase (Nox2) on days 7 and 28 of GN. ARB improved pathologic alterations such as crescent formation and glomerulosclerosis, and it had a significant inhibitory effect on the levels of these parameters on day 28 of GN. Enhanced superoxide production in nephritic glomeruli was decreased also by ARB. Moreover, Ang II and transforming growth factor beta (TGF-ß) in the supernatant of cultured glomeruli was increased significantly in vehicle-treated nephritic rats whereas ARB inhibited the production of these compounds significantly on day 28. These results indicate that increased glomerular RAS activity and the resulting Ang II play important roles in progressive glomerular injury-the induction of oxidative stress and TGF-ß expression, and they suggest that AT1R blockade attenuates proteinuria and progressive glomerular remodeling via the suppression of glomerular RAS activation in GN.

ERK5 activation enhances mesangial cell viability and collagen matrix accumulation in rat progressive glomerulonephritis.

The mitogen-activated protein kinase (MAPK) cascade plays an important role in the regulation of various cellular functions in glomerulonephritis (GN). Here, we investigated whether extracellular signal-regulated kinase 5 (ERK5), a member of the MAPK family, is involved in the pathogenesis of chronic mesangioproliferative GN, using a rat model induced by uninephrectomy and anti-Thy-1 antibody injection. Immunostaining of kidneys obtained at different time points revealed that phospho-ERK5 was weakly expressed in control glomeruli but dramatically increased in a typical mesangial pattern after 28 and 56 days of GN. A semiquantitative assessment indicated that glomerular phospho-ERK5 expression closely paralleled the accumulation of extracellular matrix (ECM), collagen type I, as well as glomerular expression of reactive oxygen species (ROS) and ANG II. On the other hand, phospho-ERK1/2 expression increased on day 7 during the phase of enhanced mesangial cell (MC) proliferation and decreased thereafter. H(2)O(2) and ANG II each induced ERK5 phosphorylation by cultured rat MCs. Costimulation with both H(2)O(2) and ANG II synergistically increased ERK5 phosphorylation in MCs. Cultured MCs transfected with ERK5-specific small interference RNA showed a significant decrease in H(2)O(2) or ANG II-induced cell viability and soluble collagen secretion compared with control cells. Treatment of GN rats with an ANG II type 1 receptor blocker resulted in significant decreases in phospho-ERK5 expression and collagen accumulation accompanied by remarkable histological improvement. Taken together, these results suggest that MC ERK5 phosphorylation by ANG II or H(2)O(2) enhances cell viability and ECM accumulation in an experimental model of chronic GN.

Glomerular angiotensinogen protein is enhanced in pediatric IgA nephropathy.

Enhanced intrarenal renin-angiotensin system (RAS) is implicated in the development and progression of renal injury. To investigate whether angiotensinogen (AGT) expression is involved in glomerular RAS activity and glomerular injury, we examined glomerular AGT expression and its correlation with expression of other RAS components, and levels of glomerular injury in samples from patients with immunoglobulin A nephropathy (IgAN) (23) and minor glomerular abnormalities (MGA) (8). Immunohistochemistry showed that AGT protein was highly expressed by glomerular endothelial cells (GEC) and mesangial cells in nephritic glomeruli of IgAN compared with glomeruli of MGA. Levels of glomerular AGT protein were well correlated with levels of glomerular angiotensin II (ang II), transforming growth factor-beta (TGF-beta), alpha-smooth-muscle actin, glomerular cell number, and glomerulosclerosis score but not with those of glomerular angiotensin-converting enzyme and ang II type 1 receptor. Real-time polymerase chain reaction (RT-PCR) and Western blot analyses using cultured human GEC indicated that ang II upregulated AGT messenger ribonucleic acid (mRNA) and protein expression in a dose- and time-dependent manner. These data suggest that activated glomerular AGT expression is likely involved in elevated local ang II production and, thereby, may contribute to increased TGF-beta production and development of glomerular injury in IgAN. Augmentation of GEC-AGT production with ang II stimulation might drive further glomerular injury in a positive-feedback loop.

[Aortic dissection associated with traumatic pericardial rupture].

We report a case of a 76-year-old man with traumatic aortic dissection complicated with cardiac herniation due to traumatic pericardial rupture. He was involved in an automobile crush and was transferred to our hospital. His vital signs were stable except for atrial fibrillation. Enhanced computed tomography (CT) showed aortic dissection on the descending aorta, multiple left rib fractures, substernal hematoma and shift of the heart toward the left chest cavity. We performed emergency operation. Through left thoracotomy, pericardial rupture was observed. Dacron graft replacement of the descending aorta and pericardial patch plasty were performed. He was discharged on the 24th postoperative day. Careful attention should be paid to aortic injury and pericardial rupture in the patient with severe blunt chest trauma.

Role of integrin-linked kinase in epithelial-mesenchymal transition in crescent formation of experimental glomerulonephritis.

BACKGROUND: Glomerular parietal epithelial-mesenchymal transition (EMT) is a key event in crescent formation of glomerulonephritis (GN). Integrin-linked kinase (ILK) is an integrin cytoplasmic-binding protein that has been implicated in the regulation of cell adhesion, extracellular matrix organization and EMT. Transforming growth factor-beta (TGF-beta) is involved in the induction and progression of EMT in several tissues. METHODS: To investigate whether ILK is involved in the crescent formation in GN, we studied the expression of ILK protein and activity in crescentic GN induced in Wistar Kyoto (WKY) rats. In addition, we investigated whether transforming growth factor-beta1 (TGF-beta1) could induce glomerular EMT and ILK by using cultured parietal epithelial cell (PEC). RESULTS: The expression of ILK was strongly induced in cellular crescents at day 7 and followed by a decrease in fibrocellular crescents at day 28. ILK-expressing cells in cellular crescents were double-positive for protein gene product 9.5 (PEC marker), alpha-smooth muscle actin (alpha-SMA, myofibroblasts marker) and TGF-beta1, indicating a possible contribution of ILK and TGF-beta1 to EMT in crescent formation in GN. Consistent with the finding of histological ILK expression in crescents, western blot and kinase activity assay showed an increase in both ILK protein and activity, peaking at day 7 of GN (3.7- and 3.5-fold of control, respectively). The expression of ILK increased to 3.1-fold of control when EMT was induced in cultured PEC by TGF-beta1. CONCLUSION: The present results provide the first evidence that expression and activity of ILK are increased in cellular crescents of experimental GN. Enhanced expression and activity of ILK, possibly by TGF-beta1, is associated with the induction of EMT by PEC and thereby, may participate in the formation of cellular crescents in GN.

Up-regulation of integrin-linked kinase activity in rat mesangioproliferative glomerulonephritis.

This study investigated whether integrin-linked kinase (ILK) is involved in the pathogenesis of chronic glomerulonephritis (GN) by analyzing the expression and activity of glomerular ILK in a chronic rat model of mesangioproliferative GN. Double immunostaining of kidneys obtained at different time points with glomerular cell-specific markers revealed that ILK was primarily expressed by glomerular epithelial cells, and weakly by mesangial cells (MCs) and endothelial cells in control rats, but dramatically increased in a typical mesangial pattern at days 21 and 28 of GN. Semiquantitative assessment indicated that the level of glomerular ILK expression closely parallels the level of accumulation of glomerular extracellular matrix (ECM) as well as fibronectin (FN). Immunoprecipitation and kinase activity assays using isolated nephritic glomeruli indicated a striking increase of ILK activity on days 21 and 28 of GN. Further, cultured rat MCs overexpressing kinase-deficient ILK diminished FN assembly and collagen matrix remodeling as compared with control transfectants. The results showed that glomerular ILK expression and activity are markedly increased in an experimental model of chronic GN. Increased activity of ILK in MCs may contribute to the development of chronic mesangial alterations leading to glomerular scarring.