Aggressive early surgical strategy in patients with intracranial hemorrhage: a new cardiopulmonary bypass option.

OBJECTIVE: We present a novel strategy in cardiac surgery with a cardiopulmonary bypass with low-dose heparin and Nafamostat mesylate as an anticoagulant (NM-CPB), which reduces postoperative neurological complications. METHOD AND RESULTS: 19 patients with a mean age of 63.6 ± 20.2 years (range 24-91) and an indication of early cardiac surgery with intracranial complication (ICC) underwent surgery with NM-CPB. The preoperative diagnoses included seven cases of infective endocarditis and six of left atrial appendage thrombosis. ICC were noticed in seven cases with hemorrhages (hemorrhagic infarction: n = 4, subarachnoid hemorrhage: n = 3) and 12 without hemorrhage (large infarction: n = 10, small-multiple infarction at the risk for hemorrhagic transformation: n = 2). The mean interval between a diagnosis and cardiac surgery was 1.1 ± 1.5 days in the ICH cases and 1.4 ± 1.4 days otherwise. In-hospital mortality was 5.3%. The mean CPB time was 146.7 ± 66.03 min, the mean dose of NM, heparin were 2.23 ± 1.59 mg/kg/hr and 56.8 ± 20.3 IU/kg, respectively. The mean activated clotting time (ACT) was 426.8 ± 112.4 s. No further intracranial bleeding and no new hemorrhages were observed after surgery. CONCLUSIONS: In early cardiac surgery with ICC, especially with hemorrhage, NM-CPB reduced postoperative neurological complications. We plan to use NM-CPB to expand the indications and to establish an early aggressive treatment.

Two Cases of Protruding Thrombus in the Ascending Aorta.

In the first case, a 60-year-old man was referred to our hospital for a sudden stomachache. A computed tomography scan revealed a thrombus at ascending aorta with acute mesenteric ischemia. In the second case, a 62-year old man developed a hypoglycemic attack with unbalanced diet. A computed tomography showed a thrombus at ascending aorta without thromboembolism. Laboratory data of both cases showed elevated platelet and a loss of antithrombin III. We administered a resection of thrombus to prevent a systemic embolism. We suggested that the risk of ascending aorta thrombus was elevated platelet and a loss of antithrombin III.

[Concomitant Surgery for Symptomatic Severe Carotid Artery Stenosis and Aortic Valve Stenosis with Contralateral Internal Carotid Artery Occlusion:A Case Report].

We report a case of concomitant carotid endarterectomy(CEA)and aortic valve replacement(AVR)for symptomatic severe carotid artery and aortic valve stenosis(AS). A 77-year-old man, presented to our hospital with AS complicated by right internal carotid artery(ICA)stenosis and left ICA occlusion, seeking treatment for AS. He suffered from left hemiparesis, and diffusion-weighted magnetic resonance imaging(MRI)showed multiple ischemic lesions in the right cerebral hemisphere. He was admitted to our neurosurgical department and received treatment for acute cerebral infarction caused by severe right ICA stenosis. The symptomatic severe right ICA stenosis was an indication for surgical treatment, but simple carotid revascularization of the stenosed ICA was considered to be deteriorated the cardiac function due to untreated AS. Thus, we decided to perform concomitant carotid and valvular surgery. The patient underwent a combined CEA and AVR procedure with the introduction of an intraoperative intra-aortic balloon pump. His postoperative course was uneventful even 12 months after the surgery. Management and surgical strategies for patients with concomitant ICA stenosis and AS continue to be controversial subjects. Combined carotid and cardiac valve surgery is considered to be effective in such cases, and we discuss its implications and review of literature.

[L-shaped Partial Upper Sternotomy Approach for Aortic Valve Replacement].

Transcatheter aortic valve implantation is a recent innovation in the treatment of severe aortic stenosis. On the other hand, several reports suggested that minimally invasive aortic valve replacement (MICS-AVR) is likely to be associated with reduced postoperative discomfort and faster recovery. Of note, an upper partial sternotomy for isolated aortic valve replacement( L-shaped MICS-AVR) has been accepted as the most common approach to the MICS-AVR. Since October 2013, we have preformed L-shaped MICS-AVR at our hospital. In L-shaped MICS-AVR group(16 patients, 74.4±8.7 years),there was no operative mortality and any other complication including reexploration for postoperative bleeding, wound infection, peri-valvular leakage, pulmonary complication like re-intubation or minitracheostomy. To demonstrate the benefits of this approach, over-octogenarian subgroup( n=7)was analyzed and compared with the isolated AVR using a conventional sternotomy (C-AVR, n=10)in the same period. A trend was seen toward better postoperative course in the L-shaped MICS-AVR group than in the C-AVR group;however, this difference was not statistically significant. The mean duration of cardiopulmonary bypass(120±29 min vs 93±24 min, p=0.005)and cross clamp time(151±36 min vs 124±32 min, p=0.038)were significantly longer than C-AVR. We believe that more clinical experience is required to clarify the benefits of this approach and we must more consider the preoperative images for the attainment of the excellent exposure. Moreover, the concomitant use of this new device and L-shaped MICS-AVR may enable a big improvement in the future.

Improvement of the in vivo cellular repopulation of decellularized cardiovascular tissues by a detergent-free, non-proteolytic, actin-disassembling regimen.

Low immunogenicity and high repopulation capacity are crucial determinants for the functional and structural performance of acellular cardiovascular implants. The present study evaluates a detergent-free, non-proteolytic, actin-disassembling regimen (BIO) for decellularization of heart valve and vessel grafts, particularly focusing on their bio-functionality. Rat aortic conduits (rAoC; n = 89) and porcine aortic valve samples (n = 106) are decellularized using detergents (group DET) or the BIO regimen. BIO decellularization results in effective elimination of cellular proteins and significantly improves removal of DNA as compared with group DET, while the extracellular matrix (ECM) structure as well as mechanical properties are preserved. The architecture of rAoC in group BIO allows for improved bio-functionalization with fibronectin (FN) in a standardized rat implantation model: BIO treatment significantly increases speed and amount of autologous medial cellular repopulation in vivo (p < 0.001) and decreases the formation of hyperplastic intima (p < 0.001) as compared with FN-coated DET-decellularized grafts. Moreover, there are no signs of infiltration with inflammatory cells. The present biological, detergent-free, non-proteolytic regimen balances effective decellularization and ECM preservation in cardiovascular grafts, and provides optimized bio-functionality. Additionally, this study implies that the actin-disassembling regimen may be a promising approach for bioengineering of acellular scaffolds from other muscular tissues, as for example myocardium or intestine. Copyright © 2017 John Wiley & Sons, Ltd.

Successful surgical treatment of traumatic sternal fracture with extensive mediastinal abscess and concomitant mitral valve endocarditis: a case report.

BACKGROUND: A traumatic sternal fracture with extensive mediastinal abscess and concomitant native valve endocarditis is an extremely rare but catastrophic situation. CASE PRESENTATION: For 2 weeks, the co-infected patient was treated with aggressive debridement for the mediastinitis, change of vacuum-assisted closure therapy dressings, vegetectomy and valve repair through lower partial sternotomy, and delayed primary wound closure. CONCLUSIONS: To the best of our knowledge, this successful staged strategy has not been previously reported. We believe that our quick decision about repeated surgical interventions and preservation of the manubrium led to a favorable result.

Rescue balloon pulmonary angioplasty under veno-arterial extracorporeal membrane oxygenation in a patient with acute exacerbation of chronic thromboembolic pulmonary hypertension.

We describe a case of a 41-year-old woman with acute exacerbation of chronic thromboembolic pulmonary hypertension (CTEPH) complicated by rapidly progressive respiratory failure and right heart failure with cardiogenic shock. A computed tomography (CT) showed thrombi in the right main pulmonary artery and bilateral peripheral pulmonary arteries, and echocardiography showed right ventricular dilatation and tricuspid regurgitation, with an estimated pressure gradient of 80 mmHg. The patient was initially diagnosed with acute pulmonary thromboembolism, and thrombolytic therapy was administered. Her condition subsequently deteriorated, however, necessitating mechanical ventilation and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We performed emergency catheter-directed thrombectomy and thrombus aspiration. Pulmonary hypertension (PH) temporarily improved, but subsequently worsened, and the patient was diagnosed with CTEPH. Pulmonary endarterectomy (PEA) was performed. After PEA, we were unable to wean the patient off VA-ECMO, and rescue balloon pulmonary angioplasty (BPA) to the middle and inferior lobe branches of the right lung was performed. Five days after BPA, the patient was removed from VA-ECMO and on the 57th day of hospitalization, she was weaned off the ventilator. The patient was discharged after 139 days of hospitalization. Rescue BPA represents a useful intervention for improving PH and weaning off VA-ECMO in a patient with acute exacerbation of CTEPH.

The degeneration of biological cardiovascular prostheses under pro-calcific metabolic conditions in a small animal model.

In order to allow for a comparative evaluation of the in vivo degeneration of biological and tissue-engineered heart valves and vascular grafts, a small animal model of accelerated cardiovascular calcification is desired. Wistar rats (n = 102; 6 groups) were fed ad libitum with regular chow and 5 different regimens of pro-calcific diet supplemented with combinations of vitamin D (VD), cholesterol (CH) and dicalcium phosphate (PH). Moreover, cryopreserved (n = 7) or detergent-decellularized rat aortic conduit grafts (n = 6) were infrarenally implanted in Wistar rats under severely pro-calcific conditions. The follow-up lasted up to 12 weeks. High-dose application of VD (300,000 IU/kg), CH (2%) and PH (1.5%) resulted in elevated serum calcium and cholesterol levels as well as LDL/HDL ratio. It increased the tissue MMP activity visualized by in situ zymography and caused significantly aggravated calcification of the native aortic valve as well as the aortic wall as assessed by histology and micro-computed tomography. (Immuno)histology and quantitative real-time PCR revealed chondro-osteogenic cell transformation, lipid deposition, nitrosative stress and low-level inflammation to be involved in the formation of calcific lesions. Despite pro-calcific in vivo conditions, decellularization significantly reduced calcification, inflammation and intimal hyperplasia in aortic conduit implants. A well balanced dietary trigger for pathologic metabolic conditions may represent an appropriate mid-term treatment to induce calcifying degeneration of aortic valves as well as vascular structures in the systemic circulation in rats. With respect to experimental investigation focusing on calcifying degeneration of native or prosthetic tissue, this regimen may serve as a valuable tool with a rapid onset and multi-facetted character of cardiovascular degeneration.

Simvastatin does not diminish the in vivo degeneration of decellularized aortic conduits.

BACKGROUND: All present biological cardiovascular prostheses are prone to progressive in vivo degeneration, which can be partially impaired by decellularization. The administration of statins may provide an additional beneficial effect. We provide the first in vivo data on the effect of statins on decellularized cardiovascular implants. METHODS: Wistar rats with aortic valve insufficiency (day 14) were fed either with a pro-calcific diet (group C; n = 17), or the same diet additionally supplemented with simvastatin (group S; n = 16). Aortic conduits from Sprague-Dawley rats were detergent-decellularized, infrarenally implanted (day 0) in all recipients and explanted at day 28 or day 84. RESULTS: Sonographic competence of the conduit perfusion was 100%, and overall survival amounted to 97%. Simvastatin decreased the low-density lipoprotein cholesterol serum levels; however, it did not affect the calcification of the implants. Histology revealed alpha-smooth muscle actin-positive intima hyperplasia in both groups. Extensive matrix metalloproteinase activity was observed in calcified areas, especially in group S. Quantitative RNA analysis resulted in no differences with regard to several markers of calcifying degeneration (alkaline phosphatase, osteopontin, osteocalcin, osteoprotegerin, bone morphogenetic protein-2, runt-related transcription factor-2) and inflammation (tumor necrosis factor α, interleukin 1ß, receptor for advanced glycation end products, CD39, CD73), but significantly lower levels of interleukin-6 in group S. CONCLUSIONS: In a standardized small animal model of accelerated cardiovascular calcification, simvastatin failed to diminish the calcification of decellularized aortic conduit implants. This finding confirms the observations of recent clinical trials. However, further experiments are warranted to elucidate the value of partial benefits associated with lower circulating lipid and proinflammatory cytokine levels.

Myofibroblasts: Biochemical and proteomic approaches to fibrosis.

Fibrosis is a state, in which excess amounts of extracellular matrix are deposited in the tissue. Fibrosis can occur in various organs, including the liver, lung, kidney and heart. The progression of fibrosis involves interstitial hypercellularity, accumulation of extracellular matrix, and atrophy of epithelial structures, resulting in a loss of normal function. Myofibroblasts play a crucial role in the development and progress of fibrosis. When stimulated, myofibroblasts actively synthesize connective tissue components and cause organ fibrosis. As a result, the process and the mechanism of myofibroblast activation represent a target for antifibrotic treatment. As yet, however, an effective treatment has not been developed, and new treatment modalities are expected. Because activation of myofibroblasts is a key event during fibrosis development, there is great interest in identifying and characterizing proteins whose expression is changed after this activation. In this review, fibrosis is outlined and the role of myofibroblasts in this disorder is described. Furthermore, the search for candidate proteins to target for treatment and the prospects of antifibrotic therapy are discussed.

Aortic conduit valve model with controlled moderate aortic regurgitation in rats: a technical modification to improve short- and long-term outcome and to increase the functional results.

BACKGROUND: The objective of this study was to describe a small animal aortic conduit model that could analyze long-term conduit valve (CV) function by echocardiography. METHODS AND RESULTS: Recipient Wistar rats (200-250g, n=20) underwent aortic leaflet injury of their native aortic valve under echocardiographic control. After 2 weeks, U-shaped decellularized CVs obtained from other rats were implanted onto the abdominal aorta. Implanted CVs were analyzed via pulsed-wave echocardiography at day 0, 4 and 12 weeks. CV stenosis was assessed as systolic flow velocity (post-pre CV)/flow velocity in the ascending aorta. CV regurgitation was assessed as the ratio of the amount of reversed diastolic flow to forward systolic flow in post-pre CV. The endpoint was set at 12 weeks. Three rats died immediately after aortic valve injury and all surviving rats received CV implantation (n=17, 85%). The survival rate after conduit implantation was 100% at 4 weeks and 88% (15/17) at 12 weeks. Regarding the CV function at 0, 4 and 12 weeks, the average observed value of CV stenosis was 3.8±7.9%, 3.1±4.1% and 14±10% (P<0.01), respectively. The average value of CV regurgitation was 0%, 12±27% and 52±43%, respectively (P<0.001). CONCLUSIONS: By using this model, the degeneration of implanted CV could be assessed not only qualitatively, but also quantitatively.

Acceleration of autologous in vivo recellularization of decellularized aortic conduits by fibronectin surface coating.

Decellularization is a promising option to diminish immune and inflammatory response against donor grafts. In order to accelerate the autologous in vivo recellularization of aortic conduits for an enhanced biocompatibility, we tested fibronectin surface coating in a standardized rat implantation model. Detergent-decellularized rat aortic conduits (n = 36) were surface-coated with covalently Alexa488-labeled fibronectin (50 µg/ml, 24 h) and implanted into the systemic circulation of Wistar rats for up to 8 weeks (group FN; n = 18). Uncoated implants served as controls (group C; n = 18). Fibronectin-bound fluorescence on both surfaces of the aortic conduits was persistent for at least 8 weeks. Cellular repopulation was examined by histology and immunofluorescence (n = 24). Luminal endothelialization was significantly accelerated in group FN (p = 0.006 after 8 weeks), however, local myofibroblast hyperplasia with significantly increased ratio of intima-to-media thickness occurred (p = 0.0002 after 8 weeks). Originating from the adventitial surface, alpha-smooth muscle actin and desmin positive cell invasion into the media of fibronectin-coated conduits was significantly increased as compared to group C (p < 0.0001). In these medial areas, in situ zymography revealed enhanced matrix metalloproteinase activity. In both groups, inflammatory cell markers (CD3 and CD68) and signs of thrombosis proved negative. With regard to several markers of cell adhesion, inflammation and calcification, quantitative real-time PCR (n = 12) revealed no significant inter-group differences. Fibronectin surface coating of decellularized cardiovascular implants proved feasible and persistent for at least 8 weeks in the systemic circulation. Biofunctional protein coating accelerated the autologous in vivo endothelialization and induced a significantly increased medial recellularization. Therefore, this strategy may contribute to the improvement of current clinically applied bioprostheses.

A novel customizable modular bioreactor system for whole-heart cultivation under controlled 3D biomechanical stimulation.

In the last decade, cardiovascular tissue engineering has made great progress developing new strategies for regenerative medicine applications. However, while tissue engineered heart valves are already entering the clinical routine, tissue engineered myocardial substitutes are still restrained to experimental approaches. In contrast to the heart valves, tissue engineered myocardium cannot be repopulated in vivo because of its biological complexity, requiring elaborate cultivation conditions ex vivo. Although new promising approaches-like the whole-heart decellularization concept-have entered the myocardial tissue engineering field, bioreactor technology needed for the generation of functional myocardial tissue still lags behind in the sense of user-friendly, flexible and low cost systems. Here, we present a novel customizable modular bioreactor system that can be used for whole-heart cultivation. Out of a commercially obtainable original equipment manufacturer platform we constructed a modular bioreactor system specifically aimed at the cultivation of decellularized whole-hearts through perfusion and controlled 3D biomechanical stimulation with a simple but highly flexible operation platform based on LabVIEW. The modular setup not only allows a wide range of variance regarding medium conditioning under controlled 3D myocardial stretching but can also easily be upgraded for e.g. electrophysiological monitoring or stimulation, allowing for a tailor-made low-cost myocardial bioreactor system.

Salicylic acid resistance is conferred by a novel YRR1 mutation in Saccharomyces cerevisiae.

Yeast cells can extrude intracellular drugs through membrane-associated efflux pumps, such as ATP-binding cassette (ABC) transporters and members of the major facilitator superfamily. Gene expression of drug efflux pumps is regulated by several transcription factors involved in pleiotropic drug resistance (PDR). Salicylic acid (SA) possesses weak antifungal activity. Although the excretion mechanisms of some antifungal drugs have been revealed, the mechanism of SA extrusion remains unclear. To elucidate the mechanism of SA excretion, we screened SA-resistant mutants from random mutagenized Saccharomyces cerevisiae BY4741 cells. We successfully isolated 60 SA-resistant clones (KinSal001-060). KinSal052, one of the strongest SA-resistant clones, also exhibited resistance to 4-nitroquinoline-1-oxide and cycloheximide, indicating that it acquired the PDR phenotype. We identified a novel mutation in YRR1 conferring SA resistance to KinSal052. YRR1 encodes a Zn(II)2Cys6-type zinc-finger transcription factor that reportedly activates gene expression involved in PDR. Yeast cells carrying the yrr1 allele (yrr1-52) activated expression of several efflux pump-encoding genes, including YOR1, SNQ2, AZR1, and FLR1. These results suggested that SA resistance in KinSal052 is conferred by the overexpression of efflux pumps constitutively activated by the mutant form of Yrr1p.

Appearance of neural stem cells around the damaged area following traumatic brain injury in aged rats.

We have previously reported free radical production after traumatic brain injury (TBI), which induces neural stem cell (NSC) degeneration and death. However, the effects of aging on NSC proliferation around the damaged area following TBI have not been investigated. Therefore, in this study, we used 10-week (young group) and 24-month-old (aged group) rat TBI models to investigate the effects of aging on NSC proliferation around damaged tissue using immunohistochemical and ex vivo techniques. Young and aged rats received TBI. At 1, 3 and 7 days after TBI, immunohistochemical and lipid peroxidation studies were performed. Immunohistochemistry revealed that the number of nestin-positive cells around the damaged area after TBI in the aged group decreased significantly when compared with those in the young group (P < 0.01). However, the number of 8-hydroxy-2'-deoxyguanosine-, 4-hydroxy-2-nonenal- and single-stranded DNA (ssDNA)-positive cells and the level of peroxidation around the damaged area after TBI significantly increased in the aged group, compared with those in the young group (P < 0.01). Furthermore, almost all ssDNA-positive cells in young and aged groups co-localized with NeuN and nestin staining. Ex vivo studies revealed that neurospheres, which differentiated into neurons and glia in culture, could only be isolated from injured brain tissue in young and aged groups at 3 days after TBI. These results indicate that, although there were fewer NSCs that have the potential to differentiate into neurons and glia, these NSCs escaped free radical-induced degeneration around the damaged area after TBI in the aged rat brain.

Neuroprotective effect of (-)-epigallocatechin-3-gallate in rats when administered pre- or post-traumatic brain injury.

Our previous study indicated that consuming (-)-epigallocatechin gallate (EGCG) before or after traumatic brain injury (TBI) eliminated free radical generation in rats, resulting in inhibition of neuronal degeneration and apoptotic death, and improvement of cognitive impairment. Here we investigated the effects of administering EGCG at various times pre- and post-TBI on cerebral function and morphology. Wistar rats were divided into five groups and were allowed access to (1) normal drinking water, (2) EGCG pre-TBI, (3) EGCG pre- and post-TBI, (4) EGCG post-TBI, and (5) sham-operated group with access to normal drinking water. TBI was induced with a pneumatic controlled injury device at 10 weeks of age. Immunohistochemistry and lipid peroxidation studies revealed that at 1, 3, and 7 days post-TBI, the number of 8-Hydroxy-2'-deoxyguanosine-, 4-Hydroxy-2-nonenal- and single-stranded DNA (ssDNA)-positive cells, and levels of malondialdehyde around the damaged area were significantly decreased in all EGCG treatment groups compared with the water group (P < 0.05). Although there was a significant increase in the number of surviving neurons after TBI in each EGCG treatment group compared with the water group (P < 0.05), significant improvement of cognitive impairment after TBI was only observed in the groups with continuous and post-TBI access to EGCG (P < 0.05). These results indicate that EGCG inhibits free radical-induced neuronal degeneration and apoptotic death around the area damaged by TBI. Importantly, continuous and post-TBI access to EGCG improved cerebral function following TBI. In summary, consumption of green tea may be an effective therapy for TBI patients.

Characteristic pattern of reactivation of hepatitis B virus during chemotherapy for solid cancers.

OBJECTIVE: A number of studies have reported reactivation of hepatitis B during intensive immunosuppressive therapy such as cases of hematological malignancy, whereas little has been reported for characteristics of reactivation triggered by chemotherapy for solid cancer. METHODS: A total of 130 patients underwent chemotherapy for treatments of common solid cancer between May 2011 and May 2012 at Kinki University Hospital. Among them, 27 patients were suspected for a past infection of hepatitis B virus (HBV), showing positive for hepatitis B core antibody or surface antibody but negative for hepatitis B surface antigen, and were eligible for this study. RESULTS: Hepatitis B reactivation was observed in 2 of 27 cases (7.4%). The duration between the start of chemotherapy and increase of serum HBV load was 30 days in both cases. CONCLUSIONS: We reported the 2 cases of hepatitis B reactivation receiving chemotherapy for solid cancer in terms of patterns and characteristics of reactivation. Accumulation of such cases will help in clarifying the clinical importance of hepatitis B reactivation during treatment of solid malignancies.

1'-acetoxychavicol acetate inhibits adipogenesis in 3T3-L1 adipocytes and in high fat-fed rats.

Alpinia galanga and Languas galanga, which are plants belonging to the ginger family, are frequently used for cooking, especially in Thai and Indonesian cuisine. The compound 1'-acetoxychavicol acetate (ACA), which is naturally obtained from the rhizomes and seeds of these gingers, has antioxidant and anti-inflammatory properties. We investigated the anti-obesity effects of ACA in 3T3-L1 adipocytes and in high fat diet (HFD)-induced rat models of obesity. ACA caused a significant decrease in the activity of GPDH in 3T3-L1 adipocytes without eliciting cell cytotoxicity, and it inhibited cellular lipid accumulation through the down-regulation of transcription factors such as PPARγ and C/EBPα. ACA also induced a dose-dependent phosphorylation of AMP-activated protein kinase (AMPK). In the animal model, rats fed an HFD containing 0.05% ACA gained less weight than rats fed an HFD alone. The visceral fat mass in rats fed an HFD containing 0.05% ACA tended to be lower than that in rats fed an HFD alone. Furthermore, a histological examination of livers from rats fed an HFD showed steatohepatitis. However, rats fed an HFD containing 0.05% ACA showed no histopathological changes in the liver tissue. Our results show that ACA exerts anti-obesity activities both in vitro and in vivo and suggests that ACA may have a novel preventive activity against obesity and possibly other metabolic diseases.