Streptococcus Mitis Endocarditis Associated with Early Gastric Carcinoma.

We report a case of Streptococcus mitis endocarditis associated with early gastric carcinoma. A 71-year-old man who had been diagnosed with aortic regurgitation (AR) two years previously was referred for valve surgery and evaluation of elevated inflammatory markers. Four months previously, atrophic gastritis, early gastric adenocarcinoma, and colon polyp had been identified in the patient during endoscopy. However, Helicobacter pylori testing was negative. On admission, he had no dental diseases or recent oral procedures. Echocardiography demonstrated severe AR and mobile vegetation on the aortic valve. Magnetic resonance imaging revealed cerebral embolism and spondylodiscitis. Blood cultures grew Streptococcus mitis. At surgery, destruction of the left cusp with vegetation and a perforation of the non-coronary cusp were found; in addition, aortic valve replacement was performed. Although the association between Streptococcus bovis bacteremia and colon neoplasm is well recognized, the association between Streptococcus mitis endocarditis and gastrointestinal carcinoma should also be kept in mind.

Rothia Aeria Endocarditis Complicated with Multiple Systemic Embolisms.

Rothia aeria is part of the normal flora in the human oral cavity and rarely causes serious systemic infection in healthy hosts. We report a case of infective endocarditis of the mitral valve due to Rothia aeria. A 53-year-old man suffered a cut on his left thumb. At the time, the patient licked the wound as a conventional way to accelerate its cure. Thereafter, he developed a recurrent fever, which was temporarily lysed with treatment using an intravenous antibiotic, over a period of 2 months after the injury. On admission, the patient had no dental caries and denied any dental procedures before onset of the fever. Auscultation revealed a systolic cardiac murmur. Echocardiography showed torn chordae of the posterior mitral leaflet with a small vegetation and severe mitral regurgitation. Two sets of blood cultures were positive for Rothia aeria. Computed tomography revealed splenic and left renal infarctions but no cerebral infarction. After resolution of the inflammation by 6 weeks of penicillin treatment, mitral valve repair was successfully performed.

Acute Mitral Regurgitation After Blunt Chest Trauma: A Case Report.

Myocardial contusion is the most common cardiac injury from blunt chest trauma (BCT), whereas isolated valve injury is uncommon. We report a case of acute mitral regurgitation (MR) due to isolated valve injury after BCT. A 60-year-old man received an impact on his left chest by a car wheel three weeks prior to visiting our hospital. At the time a diagnosis of contusion of the chest wall without rib and sternal fractures was made. Thereafter, the patient had progressive worsening of heart failure symptoms. Eventually he developed dyspnea on slight exertion but echocardiographic evaluation was not performed at the time of diagnosis or during the three weeks prior to admission. At admission a holosystolic murmur was heard. Transthoracic echocardiography revealed prolapse of the posterior mitral leaflet due to torn chordae tendineae with severe MR and normal left ventricular wall motion. At surgery, torn chordae tendineae and a leaflet tear of the posterior leaflet were detected, and mitral valve repair was achieved without residual MR. Pathological examination of the torn chordae showed no findings of endocarditis or myxomatous degeneration. Echocardiography may play an important role for accurate and prompt diagnosis of cardiac lesions in patients with recent or a history of high-energy BCT.

Anomalous Aortic Origin of the Right Coronary Artery Incidentally Detected In a Patient with Degenerative Mitral Valve Disease.

Anomalous aortic origin of a coronary artery from the opposite sinus of Valsalva is known as a cause of sudden cardiac death. However, it is often asymptomatic and incidentally diagnosed during evaluation for other cardiac diseases. We report a case of anomalous aortic origin of the right coronary artery (RCA) from the left sinus of Valsalva (ARCA) detected incidentally in a patient with degenerative mitral regurgitation (MR). A 47-year-old man, who had no history of myocardial ischemic symptoms on exertion, was admitted for sudden orthopnea. ECG revealed no ischemic changes and arrhythmias. Echocardiography demonstrated MR due to torn chordae of the posterior mitral leaflet. Computed tomography (CT) revealed the RCA arising from the left sinus of Valsalva at an acute angle and taking an interarterial course between the great arteries. The proximal RCA showed a circular shaped cross-section on CT, suggesting no presence of an intramural segment. Considering refractory heart failure and no history of myocardial ischemic symptoms on exertion as well as the findings of the CT angiography, urgent mitral valve repair was undertaken without surgical intervention for the anomalous RCA, and without evaluating myocardial ischemia. The patient recovered uneventfully. Postoperatively, myocardial perfusion scintigraphy demonstrated no exercise-induced myocardial ischemia. Patients with ARCA who are asymptomatic and whose coronary course is not intramural can be managed without surgical intervention for an anomalous coronary artery.

Pregnancy-unrelated spontaneous rupture of a right ovarian artery aneurysm.

Spontaneous rupture of an ovarian artery aneurysm is extremely rare. It can lead to retroperitoneal hemorrhage that is often life-threatening. We report a case of pregnancy-unrelated spontaneous rupture of a right ovarian artery aneurysm in a multiparous woman. A 29-year-old woman, gravida 3, para 3, whose latest pregnancy involved uneventful gestation and delivery 2 years previously, was admitted for right flank pain. The urine test result for pregnancy was negative. Computed tomography revealed a large retroperitoneal hematoma and right ovarian artery aneurysm with contrast extravasation. After selective angiography, embolization of the right ovarian artery was successfully achieved using microcoils. Diagnostic angiography with subsequent transcatheter arterial embolization is an effective and less invasive technique for the management of ovarian artery aneurysm.

Aortic valve replacement for dextrocardia with situs inversus totalis.

Dextrocardia is a rare congenital cardiac positional anomaly. A 74-year-old woman was referred for aortic regurgitation (AR). Chest X-ray revealed a mildly enlarged heart that directed to the right side. Transthoracic echocardiography showed AR due to cusp prolapse with a dilated left ventricle and reduced wall motion. Computed tomography demonstrated the heart and great vessels in a mirror image of their normal positions. A median sternotomy performed by the surgeon standing on the right side of the patient. After establishing a cardiopulmonary bypass, the surgeon moved to the left side of the patient, and then performed aortic valve replacement.

Use of Edoxaban for the Treatment of Heparin-Induced Thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is a life-threatening adverse drug reaction of heparin therapy, which increases a patient's risk of developing venous and/or arterial thromboembolism. HIT should be treated through discontinuation of heparin and administration of nonheparin anticoagulants such as argatroban. For long-term anticoagulation, parenteral nonheparin anticoagulants are generally converted to oral treatment with a vitamin K antagonist such as warfarin. Although administration of warfarin is recommended to overlap with a nonheparin anticoagulant for a minimum of 5 days, overlapping with argatroban and warfarin presents high risks of bleeding. We describe a case of HIT treated with edoxaban. A 78-year-old man underwent surgery for esophageal cancer and was administered heparin perioperatively. After surgery, he was diagnosed with HIT and venous thromboembolism. We immediately stopped heparin and initiated parenteral argatroban. The patient was subsequently started on edoxaban without any overlap between the two drugs. The treatment was successful. The treatment of edoxaban following argatroban for HIT could reduce bleeding complications and shorten the length of hospital stay. To the best of our knowledge, this is the first report of the use of edoxaban for HIT treatment.

Acute heart failure due to large intimal flap associated with chronic aortic dissection.

Acute heart failure from aortic stenosis secondary to chronic aortic dissection is very rare. We describe a case of acute heart failure secondary to aortic arch stenosis resulting from subacute type A aortic dissection. Resection of large thickened immobile intimal flap with total aortic arch replacement was successful, and cardiac function improved.

The Role of Syk in Inflammatory Response of Human Abdominal Aortic Aneurysm Tissue.

Objective: Inflammatory response is central to pathogenesis of abdominal aortic aneurysm (AAA). Recently, we reported that Syk, a signaling molecule in inflammatory cells, promotes AAA development in a mouse model. In this study, we aimed to investigate the role of Syk in human AAA pathogenesis. Materials and Methods: We obtained human AAA wall samples during open surgical aortic repair at Kurume University Hospital. Immunohistochemical analyses of AAA samples were performed for Syk activation and cell type markers. Ex vivo culture of human AAA tissue was utilized to evaluate the effect of P505-15, a Syk inhibitor, on secretions of interleukin-6 (IL-6) and matrix metalloproteinases (MMPs). Results: Immunohistochemical analysis showed infiltration of B cells, T cells, and macrophages in AAA samples. Syk activation was localized mainly in B cells and part of macrophages. AAA tissue in culture secreted IL-6, MMP-9, and MMP-2 without any stimulation. The unstimulated secretions of IL-6, MMP-9, and MMP-2 were insensitive to P505-15. Secretions of IL-6 and MMP-9 were enhanced by exogenous normal human immunoglobulin G (IgG), which was suppressed by P505-15, whereas secretion of MMP-2 was insensitive to IgG or P505-15. Conclusion: These results demonstrate an important role of Syk for IgG-dependent inflammatory response in human AAA.

Surgical repair of Stanford type A acute aortic dissection with extreme tuberculosis-related mediastinal deviation.

In this article, we report on the case of an 85-year-old woman with a history of left pulmonary tuberculosis, who was referred for Stanford type A acute aortic dissection. A preoperative chest X-ray and computed tomography revealed extreme mediastinal deviation to the left. We decided to perform surgery with left rib-cross thoracotomy. This approach yielded excellent exposure of the aortic root, ascending aorta and aortic arch. Following an uneventful operative and postoperative course, the patient was discharged on the 21st postoperative day.

Florida sleeve technique for a right sinus of Valsalva aneurysm: a case report.

BACKGROUND: Florida sleeve technique was reported by Hess et al. as a new technique of valve sparing aortic root replacement without the requirement of entire aortic root wall resection and coronary artery reconstruction. We present a rare case of an unruptured aneurysm of the right sinus of Valsalva that was successfully treated with resection of the aneurysm and the Florida sleeve technique. CASE PRESENTATION: A 72-year-old man was admitted for the treatment of an unruptured aneurysm of the right sinus of Valsalva. Computed tomography showed an aneurysm of the right sinus of Valsalva measuring > 40 mm and protruding into the right ventricular outflow tract. The aneurysm dilated up to 5 mm per year, and the left sinus of Valsalva and non-coronary sinus of Valsalva also showed dilation, and he underwent resection of only the right sinus of Valsalva aneurysm and valve sparing aortic root replacement with the Florida sleeve technique. CONCLUSIONS: We performed valve-sparing aortic root replacement with the Florida sleeve technique. It could reduce surgical risks and prevent a dilatation of the residual sinus of Valsalva through coverage with a graft for a long term.

Activation of the AKT Pathway in the Ascending Aorta With Bicuspid Aortic Valve.

BACKGROUND: Dilatation of the ascending aorta affects those patients with bicuspid aortic valve (BAV), even after valvular surgery, possibly due to tissue fragility. The goal of the study was the molecular characterization of aorta with BAV compared to that with normal tricuspid aortic valve (TAV). Methods and Results: The subjects were patients who underwent surgery for aortic valve stenosis in 2013 and 2014. Nine patients with BAV and 13 with TAV were examined. There was no difference in the clinical characteristics or grade of aortic valve stenosis, but the diameters of the ascending aorta were significantly higher in the BAV group. The ascending aortic specimens were subjected to transcriptome analyses, which revealed the changes in receptor tyrosine kinase (RTK) pathway-related genes between TAV and BAV samples. Immunohistochemical study revealed higher staining of phosphorylated AKT (pAKT) in the media of the ascending aorta in the BAV group, regardless of the size of ascending aorta, whereas total AKT did not show such a difference. Immunofluorescence staining revealed the AKT activation was mainly in the medial vascular smooth muscle cells. CONCLUSIONS: The results showed that the RTK-AKT pathway in the medial layer of the ascending aorta is activated in aortae with BAV. Activation of this pathway may be associated with fragility and dilatation of the ascending aorta with BAV.

Characterization of SMAD2 Activation in Human Thoracic Aortic Aneurysm.

Objective: Thoracic aortic aneurysm (TAA) reflects the local expansion of the thoracic aorta; the underlying causal molecular mechanism of TAA is not well understood. Recent studies have shown the importance of transforming growth factor beta (TGFß) signaling in Marfan and Loeys-Dietz syndromes; however, its role in non-familial, non-syndromic TAA remains unclear. Materials and Methods: We performed histochemical and immunohistochemical analyses for activated (phosphorylated) SMAD2 (P-SMAD2) as an indicator of TGFß signaling activities in the ascending TAA tissue as well as in the ascending aortic tissue with a normal diameter obtained from 7 patients without any clinical findings suggesting familial or syndromic TAA. Results: TAA samples showed a higher P-SMAD2-positive area than samples with a normal diameter. P-SMAD2 signal was higher in the outer zone of the aortic and TAA walls. Within the TAA tissue, P-SMAD2 staining showed the following two distinct patterns: layer-like staining at the border of the medial layer and the thickened intima and a spot-like staining within the medial layer surrounding the microvessels. Conclusion: These findings suggested that TGFß signaling is activated in several distinct histopathological contexts in TAA, suggesting a complex role of TGFß.

Enlargement of the Excluded Left Atrial Appendage With Thrombus.

We report progressive enlargement of the excluded left atrial appendage (LAA) with a thrombus in a patient who had undergone valve surgery and endocardial suture closure of the LAA previously. Echocardiography and CT detected no communication between the LAA and the left atrium. Magnetic resonance imaging showed the LAA was filled with fresh and old thrombi. Coronary arteriography demonstrated small left coronary artery-LAA fistulae. At surgery, successful exclusion of the LAA was confirmed after removal of the thrombi. Persistent inflow of blood through the coronary artery fistulae to the excluded LAA may be the primary mechanism of this pathology.

Successful Surgical Treatment of a Huge Candida albicans Aortic Fungus Ball with Pseudoaneurysm.

A 70-year-old woman with a history of aortic valve replacement and coronary artery bypass grafting (CABG) was transferred to the authors' hospital for further management of a three-month fever of unknown origin. Computed tomography showed a huge mass in the ascending aorta with pseudoaneurysm. Blood ß-D-glucan levels were significantly high, and blood culture showed the growth of Candida albicans. The fungus ball was excised surgically, together with aortic root replacement and CABG, followed by six-month postoperative anti-fungal therapy. Early diagnosis by imaging studies followed by aggressive surgery and long-term postoperative antifungal treatment should result in a favorable outcome.

Double Right Atrial Blood Cysts.

Blood cysts are exceedingly rare benign cardiac tumors, generally involving the cardiac valves. They are found mainly in the first month of life and in children and are very uncommon in adults. We present a rare case of double right atrium blood cysts, incidentally detected by transthoracic echocardiography in an 85-year old patient.

Therapeutic strategy for treating aortoesophageal fistulas.

PURPOSE: The development fistulas between the thoracic aorta and the esophagus are highly fatal conditions. We aimed to identify a therapeutic strategy for treating aortoesophageal fistula (AEF) in this study, by investigating all AEF cases presented in this special symposium at the 65th Annual Scientific Meeting of the Japanese Association for Thoracic Surgery. METHODS: Forty-seven AEF patients were included in this study. The survivors and nonsurvivors at six and 18 months after diagnosis of AEF were classified into "Group A6", "Group D6", "Group A18", and "Group D18", respectively. Comparisons between Group A6 and Group D6 and between Group A18 and Group D18 were made with regard to therapeutic strategy. RESULTS: Twenty-two (46.8 %) and 33 (70.3 %) of the 47 patients died within 6 and 18 months, respectively. The patients treated with omentum wrapping (p = 0.0052), esophagectomy (p = 0.0269) and a graft replacement strategy for the aorta (p = 0.002) were more frequently included in Group A6. The patients with the omentum wrapping (p = 0.0174) and esophagectomy (p = 0.0203) and graft replacement were more significantly included in Group A18. The results of the multivariate analysis indicated that the mortality rate at 6 and 18 months after diagnosis was significantly correlated with graft replacement (p = 0.0188) and esophagectomy (p = 0.0257), respectively. There were significant differences in the actuarial survival curves in patients who had omentum wrapping, graft replacement, and esophagectomy compared to patients who did not have these 3 therapeutic procedures. CONCLUSION: The use of thoracic endovascular aortic repair alone for AEF should not be considered a definitive surgery. In contrast, esophagectomy, open surgery with aortic replacement using prostheses and homografts and greater omentum wrapping significantly improve the mid-term survival of AEF.

Intracardiac metastasis of esophageal squamous cell carcinoma -report of a case-.

We report a case of a 48-year-old man with a history of violent coughing fits and general fatigue underwent urgent surgery for cardiac tamponade, and who was later diagnosed with metastatic intracardiac squamous cell carcinoma of the esophagus. After admittance to Munakata Suikokai General Hospital, Fukuoka, Japan, echocardiography showed extensive pleural and pericardial effusion and a mass, 4 by 2 cm, with a solid echo pattern in the right ventricular cavity. The working diagnosis was primary malignant cardiac tumor of unknown origin with multiple metastases. To prevent sudden death due to obliteration of the outflow tract of the right ventricle, we performed urgent surgery for cardiac tamponade. Histological examination of the resected tumor revealed squamous cell carcinoma. Fiberoptic esophagoscopy showed hypertrophy of the esophageal wall and a submucosal tumor extending throughout the esophagus. Microscopic examination of the esophagus biopsy specimen showed moderately differentiated squamous cell carcinoma, the histology of which was similar to that of the resected tumor and cytology of pericardial effusion. The patient recovered and was able to return home for a few days; however, he was readmitted, and despite maximal supportive therapy, he died one month after the operation.

A case of angioleiomyoma presenting as a pulsatile tumor in the left ring finger.

Angioleiomyomas in the finger are rare and their preoperative diagnosis is difficult. Most of them are not associated with arteries and their chief complaint does not reveal pulsation tumor. We report a case of the angioleiomyoma in the finger which was misdiagnosed as arteriovenous fistula of tumor, based on the presence of pulsating tumor and angiography finding.

Preoperative visualization of the artery of Adamkiewicz by dual-phase CT angiography in patients with aortic aneurysm.

To improve our ability to visualize the Adamkiewicz artery (AKA), we developed a modified intravenous CT angiography technique, which we refer to as right atrial CT (RA-CT) angiography. In this study, AKA detection rate and visualization of the arterial continuity from the aorta to the anterior spinal cord artery (ASA) was evaluated using RA-CT angiography.We performed RA-CT angiography in 110 patients with abdominal, thoracic descending, or thoracoabdominal aortic aneurysms. In RA-CT angiography, contrast medium with a high iodine concentration (370 mg/dl) was injected twice into the right atrium at a high injection rate (8.0 ml/sec), and two CT scans, starting at 20 sec after the first injection and at 35 sec after the second injection, respectively, were performed. All CT images were obtained using an 8- or 16-detector CT scanner at a slice thickness of 0.625 mm. The AKA was defined as the largest radiculomedullary artery with a characteristic hairpin turn, and with continuity from the aorta to the ASA.The AKA with hairpin turn was detected in all patients (100%), and continuity from the aorta to the ASA was confirmed in 99 of the 110 patients (90.0%). The AKA arose between Th8 and L1 in 86 of these patients (86.8%), and originated from the left side in 71 patients (71.7%).RA-CT angiography may be useful for visualizing the AKA and the arterial continuity from the aorta to the ASA in patients with aortic aneurysm, although the use of more advanced CT machines will provide safe and easy identification of the AKA and arterial continuity with a small amount of contrast medium and a single scan.