Mitral valve repair for infective endocarditis after esophageal reconstruction: a case report.

BACKGROUND: In patients with retrosternal neo-esophageal conduit after right thoracotomy, the approach to cardiac surgery could be challenging. Particularly, in patients with infective endocarditis, there is a risk of injury to the conduit through standard median sternotomy. Moreover, right lung adhesions could be predicted. Herein, we present a case of successful mitral valve repair in a patient with infective endocarditis through a redo right thoracotomy after esophageal reconstruction. CASE PRESENTATION: A 66-year-old male patient was diagnosed with infective endocarditis and a large anterior mitral leaflet vegetation after a previous esophageal reconstruction via right thoracotomy for esophageal cancer. Due to the retrosternal esophageal reconstruction, we performed a mitral valve repair through a redo right thoracotomy. After resecting the vegetation, the defect was closed with a fresh autologous pericardial patch. Mitral valve annuloplasty was performed. Postoperatively, antibiotics controlled the infection. The patient was discharged on postoperative day 30. CONCLUSIONS: Successful mitral valve repair was performed for infective endocarditis through a redo right thoracotomy after esophageal reconstruction.

Filter-type Protection Device Retrieval Interfered by Deployed Stent during Subclavian Artery Stenosis Treatment: Case Report and Complication Avoidance Recommendation.

Endovascular treatment is a standard procedure for subclavian artery stenosis or obstruction. However, great care should be taken to avoid embolic complications to the vertebral artery, and several methods have previously been reported. Hence, as surgical procedures become increasingly complicated, unintended issues may arise during treatment. Here, the authors report a case where the filter-type protection device was caught in the stent because the patient moved during treatment, leading to open surgery to recover the filter-type protection device． A 78-year-old female suffering from a left subclavian steal syndrome underwent stenting due to subclavian artery stenosis. The stenotic lesion was approached via the transfemoral route, and a filter-type protection device was advanced to the vertebral artery via the transbrachial route to prevent embolic complications. As the procedure was performed under local anesthesia, the patient moved during stent deployment proximally to the left vertebral artery origin, and the stent unintentionally advanced distally, covering the vertebral artery and obstructing the retrieval catheter for the filter-type protection device to advance. Failed attempts in recovering the filter-type protection device required open surgery for retrieval. Fortunately, there was no postoperative neurological and radiographic complication, ameliorating her chief complaint． The retriever catheter for the protection device should be advanced beyond the vertebral artery orifice just proximal to the protection device before stenting to avoid such complications while also thoroughly considering the type of anesthesia during treatment．.

The impact of postoperative cerebrospinal fluid drainage on neurological improvement following thoracic aortic and thoracoabdominal aortic surgery.

Background: Various preventive measures and treatment methods exist to prevent paraplegia during thoracic aortic surgery. Postoperative cerebrospinal fluid drainage (CSFD) is one of the treatment options when paraplegia occurs. This study aimed to evaluate the neurological efficacy of postoperative CSFD in patients undergoing thoracic aortic and thoracoabdominal aortic surgery. Methods: We analyzed perioperative data from 85 patients who underwent perioperative CSFD for thoracic and thoracoabdominal aortic surgery between January 2006 and December 2022, focusing on neurological changes. A total of 61 patients (72%) received preoperative CSFD, and 24 patients (28%) received postoperative CSFD. Perioperative neurological data were analyzed with a focus on perioperative changes. Results: In the postoperative CSFD group, the manual muscle test (MMT) score before CSFD was 0.8, that just after CSFD was 2.4, and that at discharge was 3.0. Therefore, postoperative CSFD improved MMT scores compared with preoperative CSFD. The mean time between surgery completion and postoperative CSFD implantation was 9.8 hours. However, 6 (25%) of the patients who developed postoperative paraplegia and underwent early postoperative CSFD remained paraplegic without any improvement. In the preoperative CSFD group, there was only one case (2%) of postoperative paraplegia. Conclusions: Postoperative CSFD improved the neurological prognosis of individuals undergoing thoracic aortic and thoracoabdominal aortic surgery. However, 25% of the patients remained paraplegic despite postoperative CSFD.

Outcomes of Vascular Surgery Performed Jointly With Other Departments.

OBJECTIVE: The purpose of this study is to evaluate the results of vascular surgery performed at our hospital, a tertiary emergency general hospital, in patients undergoing surgery in other departments. The results of the study were reviewed. METHODS: The study included cases in which cardiovascular surgery was performed at the request of other departments over a 15-year period from January 2006 to October 2022. Patient backgrounds, departments that requested surgery, surgical procedures, use of extracorporeal circulation, and surgical techniques were reviewed. Patients with femoral artery exposure or ECMO removal during transcatheter aortic valve implantation (TAVI) requested by cardiology were excluded. RESULTS: There were 58 vascular surgery cases requested by other departments during the study period. The age was 63±14 years, 43 (74%) were male and 15 (26%) were female. The departments of the patients were urology in 29 (50%), gastroenterology in 18 (31%), orthopedics in seven (12%), emergency department in three (5%), and obstetrics and gynecology in one (2%). The following surgical procedures were performed: tumor resection and reconstruction due to tumor invasion of the inferior vena cava in 27 cases (47%), bypass to secure intraperitoneal arterial blood flow in 15 cases (26%), bypass during resection of the femoral tumor in four cases (7%), hemostasis due to trauma in three cases (5%), intraperitoneal hemostasis in three cases (5%), thrombectomy in two cases (3%), and others in four cases (7%). Extracorporeal circulation was used in six (10%) of the patients. CONCLUSION: A 15-year case study of vascular surgery supports operations requested by other departments at our hospital. All reconstructed sites were open at the time of discharge.

One Year Outcomes of Zilver PTX Versus Eluvia for Femoropopliteal Disease in Real-World Practice: REALDES Study.

PURPOSE: This multicenter, prospective, observational study aimed to compare Zilver PTX and Eluvia stents in real-world settings for treating femoropopliteal lesions as the differences in the 1-year outcomes of these stents have not been elucidated. MATERIALS AND METHODS: Overall, 200 limbs with native femoropopliteal artery disease were treated with Zilver PTX (96 limbs) or Eluvia (104 limbs) at 8 Japanese hospitals between February 2019 and September 2020. The primary outcome measure of this study was primary patency at 12 months, defined as a peak systolic velocity ratio of ≤2.4, without clinically-driven target lesion revascularization (TLR) or stenosis ≤50% based on angiographic findings. RESULTS: The baseline clinical and lesion characteristics of Zilver PTX and Eluvia groups were roughly comparable (of all limbs analyzed, approximately 30% presented with critical limb-threatening ischemia, approximately 60% presented with Trans-Atlantic Inter-Society Consensus II C-D, and approximately half had total occlusion), except for the longer lesion lengths in the Zilver PTX group (185.7±92.0 mm vs 160.0±98.5 mm, p=0.030). The Kaplan-Meier estimates of primary patency at 12 months were 84.9% and 88.1% for Zilver PTX and Eluvia, respectively (log-rank p=0.417). Freedom from clinically-driven TLR rates were 88.8% and 90.9% for Zilver PTX and Eluvia, respectively (log-rank p=0.812). CONCLUSIONS: The results of the Zilver PTX and Eluvia stents were not different regarding primary patency and freedom from clinically-driven TLR at 12 months after treating patients with femoropopliteal peripheral artery disease in real-world settings. CLINICAL IMPACT: This is the first study to reveal that the Zilver PTX and Eluvia have similar results in real-world practice when the proper vessel preparation is performed. However, the type of restenosis in the Eluvia stent may differ from that in the Zilver PTX stent. Therefore, the results of this study may influence the selection of DES for femoropopliteal lesions in routine clinical practice.

Initial Outcomes of Physician-Modified Inner Branched Endovascular Repair in High-Surgical-Risk Patients.

PURPOSE: To report the initial outcomes of physician-modified inner branched endovascular repair (PMiBEVAR) for pararenal aneurysms (PRAs), thoracoabdominal aortic aneurysms (TAAAs), and aortic arch aneurysms in high-surgical-risk patients. MATERIALS AND METHODS: A total of 10 patients (6 men; median age, 83.0 years) treated using PMiBEVAR were enrolled in this retrospective, single-center study. All patients were at high surgical risk because of severe comorbidities (American Society of Anesthesiologists physical status score≥3 or emergency repair). End points were defined as technical success per patient and per vessel (successful deployment), clinical success (no endoleaks postoperatively), in-hospital death, and major adverse events. RESULTS: There were 3 PRAs, 4 TAAAs, and 3 aortic arch aneurysms with 12 renal-mesenteric arteries and 3 left subclavian arteries incorporated by inner branches. The technical success rate was 90.0% (9/10) per patient and 93.3% (14/15) per vessel. The clinical success rate was 90% (9/10). There were 2 in-hospital deaths, unrelated to aneurysms. Paraplegia and shower emboli occurred separately in 2 patients. Three patients experienced prolonged ventilation for 3 days after surgery. Aneurysm sac shrinkage occurred in 4 patients, and aneurysm size stabilized in 1 patient during follow-up, more than 6 months later. None of the patients required intervention. CONCLUSION: PMiBEVAR is a feasible approach for treating complex aneurysms in high-surgical-risk patients. This technology may complement the existing technology in terms of improved anatomical adaptability, no time delay and practicability in many countries. However, long-term durability remains undetermined. Further large-scale and long-term studies are needed. CLINICAL IMPACT: This is the first clinical study to investigate outcomes of physician-modified inner branched endovascular repair (PMiBEVAR). PMiBEVAR for treating pararenal aneurysm, thoracoabdominal aortic aneurysm, or aortic arch aneurysm is a feasible procedure. This technology is likely to complement existing technology in terms of improved anatomical adaptability (compared to off-the-shelf devices), no time delay (compared to custom-made devices), and the potential to be performed in many countries. On the other hand, surgery time varied greatly depending on the case, suggesting a learning curve and the need for technological innovation to perform more consistent surgeries.

[Mullerian Cyst in the Posterior Mediastinum Resected by Robot-assisted Thoracic Surgery:Report of a Case].

Mullerian cyst in the posterior mediastinum is a rare disorder. We report on the case of a woman in her 40s with a cystic nodule which is located in the right posterior mediastinum next to the vertebra at the level of tracheal bifurcation. The tumor was suggested to be cystic by preoperative magnetic resonance imaging (MRI). The tumor was resected with robot-assisted thoracic surgery. Pathology by hematoxylin-and-eosin (H&E) revealed a thin-walled cyst lined by ciliated epithelium without cellular atypia. The diagnosis of Mullerian cyst was confirmed by immunohistochemical staining which showed the positive findings for estrogen receptor (ER) and progesterone receptor of the lining cells.

Coronary Artery Bypass Grafting Using the No-Touch Great Saphenous Vein Graft Harvesting Technique: A Retrospective Study.

Background We focused on coronary artery bypass grafting using the great saphenous vein and compared the no-touch great saphenous vein and conventional great saphenous vein. Methods Coronary artery bypass grafting using the great saphenous vein was performed at our hospital over a 15-year period from 2007/04 to 2022/08. The primary endpoint was the patency of the great saphenous vein at discharge, and secondary endpoints were delayed healing of the great saphenous vein harvest wound, delayed healing of the mid-thoracic wound, and factors related to coronary artery bypass surgery. Results There were 183 patients who underwent coronary artery bypass surgery using the great saphenous vein during the study period. There were 131 male patients (72%) and 52 female patients (28%) with a mean age of 69 years (38-94 years). The method of harvesting the great saphenous vein was a no-touch great saphenous vein graft (NT-SVG) in 29 cases (16%) and conventional SVG in 154 cases (84%). Patients were divided into two groups: the NT-SVG group and the standard-collection saphenous vein graft (SVG) group. We compared graft patency at discharge, healing failure of the lower leg wound, healing failure of the mid-thoracic wound, and flow by transit-time flow measurement (TTFM). Conclusion There were no significant differences in perioperative outcomes between the NT-SVG and conventional SVG groups in this study.

[Acute Cardiac Tamponade Caused by Hemorrhage from Cardiac Hemangioma:Report of a Case].

A 68-year-old man with acute chest pain was transported into the emergency room in our hospital. He was in shock, with a systolic blood pressure of 63 mmHg and a heart rate of 115 beats per minute. Echocardiography revealed a cardiac tamponade, but no signs of acute aortic dissection were found by computed tomography. He immediately underwent pericardial fluid drainage and was transferred to the operation theatre. Pericardiotomy was performed and hemorrhage from the right atrium was found. Then, a mass of 35 mm in diameter was also detected by transesophageal echocardiography. Resection of the right atrial tumor was performed under cardiopulmonary bypass. A bovine pericardial patch was used for the repair of the defect in the right atrium. The pathological diagnosis was cardiac hemangioma with no malignant signs.

Morphological predictor of remodelling of the descending thoracic aortic false lumen that remains patent after repair of acute type A dissection.

OBJECTIVES: Some patients achieve complete recovery through false lumen remodelling in the descending aorta after surgery for acute type A aortic dissection. Our goal was to investigate the relationship between false lumen remodelling during later postoperative stages and quantitative analysis of the true lumen shape during the early postoperative stages. METHODS: We examined 88 surgical patients between January 2007 and December 2016. Three points of the descending aorta were assessed from the 6th (T6), the 9th (T9) and the 11th (T11) vertebral levels. The shape of the true lumen was evaluated during the early postoperative stages, and false lumen remodelling 1 year after surgery was the end point. The parameters obtained by evaluating the shape of the true lumen comprised the first principal component analysis using elliptic Fourier analysis, the minor diameter ratio and the ratio of the area of the true lumen to that of the descending aorta, and the number of contact points on the true lumen wall during the early stages. RESULTS: Using univariate analysis, we detected significant differences in the first principal components, the minor diameter ratio, the area ratio and the number of contact points at each thoracic vertebral level (P < 0.05). The cut-off value of the minor diameter ratio was 0.55, and the area ratio was 0.48 as determined by analysis of the receiver operating characteristic. Multivariable logistic analysis indicated that the first principal component was the most significant predictor from the proximal to the middle descending aorta. CONCLUSIONS: Quantitative evaluation of shape of the true lumen in the early postoperative stages after surgery for acute type A dissection can serve as a viable predictor for false lumen remodelling in later stages. Furthermore, the first principal component could serve as a more astute predictor than other quantitative parameters according to multivariate analysis.

Relationship between onset of spontaneous pneumothorax and weather conditions.

OBJECTIVES: Spontaneous pneumothorax (SP) results from the rupture of blebs or bullae. It has been suggested that changes in weather conditions may trigger the onset of SP. Our aim was to examine the association between the onset of primary SP with weather changes in the general population in Sapporo, Japan. METHODS: From January 2008 through September 2013, 345 consecutive cases with a diagnosis of primary SP were reviewed. All cases of primary SP developed in the area within 40 km from the Sapporo District Meteorological Observatory. Climatic measurements were obtained from the Observatory, which included 1-h readings of weather conditions. Logistic regression model was used to obtain predicted risks for the onset of SP with respect to weather conditions. RESULTS: SP occurred significantly when the atmospheric pressure decreased by - 18 hPa or less during 96 h before the survey date (odds ratio = 1.379, P = 0.026), when the pressure increased by 15 hPa or more during 72 h before the survey date (odds ratio = 1.095, P = 0.007) and when maximum fluctuation in atmospheric pressure over 22 hPa was observed during 96 h before the survey date (odds ratio = 1.519, P = 0.001). Other weather conditions, including the presence of thunderstorms, were not significantly correlated with the onset of pneumothorax. CONCLUSIONS: Changes in atmospheric pressure influence the onset of SP. Future studies on the relationship between the onset of SP and weather conditions on days other than before the onset and with large number of patients may enable us to predict the onset of SP in various regions and weather conditions.

New predictor of aortic enlargement in uncomplicated type B aortic dissection based on elliptic Fourier analysis.

OBJECTIVES: This study aimed to re-examine the conventional predictive factors for dissected aortic enlargement, such as the aortic and false lumen diameter and to consider whether the morphological elements of the dissected aorta could be predictors by quantifying the 'shape' of the true lumen based on elliptic Fourier analysis. METHODS: A total of 80 patients with uncomplicated type B aortic dissection were included. The patients were divided into 'Enlargement group' and 'No Change group.' Between the 2 groups, the mean systolic blood pressure during follow-up, aortic and false lumen maximum diameters, and analysed morphological data were compared using each statistical method. RESULTS: The maximum aortic and false lumen diameters were significantly larger in the Enlargement group than in the No Change group (39.3 vs 35.9 mm; P = 0.0058) (23.5 vs 18.2 mm; P = 0.000095). The principal component 1, which is the data calculated by elliptic Fourier analysis, was significantly lower in the Enlargement group than in the No Change group (0.020 vs - 0.072; P = 0.000049). The mean systolic blood pressure ≥130 mmHg, aortic diameter, false lumen diameter and principal component 1 were included in the Cox proportional hazard model as covariates to determine the significant predictive variable. Principal component 1 demonstrated the only significance with aortic enlargement on multivariate analysis (odds ratio = 0.32; P = 0.048). CONCLUSIONS: The analysed and calculated morphological data of the shape of the true lumen can be more effective predictive factors of aortic enlargement of type B dissection than the conventional factors.

[Aortic prosthetic valve endocarditis with aorto-left atrium fistula; report of a case].

An 83-year-old man had undergone aortic valve replacement (AVR)[CEP Magna 21 mm] and coronary aortic bypass grafting (CABG)[left internal thoracic artery (LITA)-left anterier descending artery( LAD)] 2 years ago in our hospital. He was admitted for fever of unknown origin and developed a stroke to another hospital. The echocardiography and computerized tomography showed an abscessaround the aortic prosthetic valve. Prosthetic valve endocarditis (PVE) was diagnosed, and he was transferred to our hospital for surgical treatment. Three days after admission, acute heart failure developed that led to an emergency operation. When the ascending aorta was dissected, an aorto-left atrium fistula and vegetation were recognized. Aortic valve replacement and patch plasty of the aorto-left atrium fistula were performed successfully. This case was diagnosed as PVE with aorto-left atrium fistula, which is quite a rare complication of PVE.

[Henoch-Schönlein Purpura with lung abscess].

A 72-year-old man had underwent left lower lobectomy for squamous cell carcinoma in our hospital in 2008. Postoperative stage was I A (T1N0M0). In 2010, follow-up chest computed tomography (CT) images showed similar cavitary nodules in segments 2 and 8 of the right lung with positive uptake on fluorodeoxyglucose-positron emission tomography (FDG-PET) images. Physical examination, blood tests, and levels of serum tumor markers showed no abnormality. Transbronchial lung biopsy revealed the absence of malignant cells. Segment 8 of the right lower lobe with the nodule was partially resected, and pathological examination demonstrated lung abscess. He was discharged but was hospitalized in another hospital for purpuric rash, fever, and arthralgia. Microscopic albuminuria was noted, and renal biopsy revealed nephritis with immunoglobulin A( IgA)deposition. He was made a diagnosis of Henoch-Schönlein purpura. Oral steroid therapy( prednisolone 60 mg/d) was initiated, resulting in the improvement of symptoms and disapearance of the cavitary nodule in the right lung segment 2.

Surgical treatment for primary lung cancer combined with idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is defined as a specific form of chronic, progressive fibrosing interstitial pneumonia of unknown cause. IPF is associated with an increased risk of lung cancer, and lung cancer patients with IPF undergoing pulmonary resection for non-small cell lung cancer have increased postoperative morbidity and mortality. Especially, postoperative acute exacerbation of IPF (AEIPF) causes fatal status and long-term outcomes are worse than for patients without IPF, although certain subgroups have a good long-term outcome. A comprehensive review of the current literature pertaining to AEIPF and the late phase outcome after the context of a surgical intervention was performed.

Ischemic Colitis Following Transarterial Embolization for Type 2 Endoleak of EVAR: Report of a Case.

A 71 year old man was diagnosed to have enlargement of abdominal aortic aneurysm due to type 2 endoleak two years after endovascular aneurysm repair (EVAR). 3D-CT demonstrated a type 2 endoleak that originated from the superior mesenteric artery that fed the inferior mesenteric artery and the right iliolumbar artery that flowed into the 4th lumbar artery. Transarterial embolization was performed by means of N-butyl-2-cyanoacrylate (NBCA). After the treatment, he suffered ischemic colitis that extended from the sigmoid colon to the descending colon. Conservative treatment was mainly performed, and clinical improvement was observed over time. He was discharged after 73 postoperative days.

Total thoracoscopic lung segmentectomy of anterior basal segment of the right lower lobe (RS8) for NSCLC stage IA (case report).

A 69-year-old woman with a pulmonary nodule in anterior basal segment of the right lower lobe (RS8) was referred to our department. The diameter of the tumor was 12 mm, and it had increased over a few months. First, video-assisted thoracoscopic lung surgery (VATS) biopsy of the pulmonary nodule was carried out. Frozen section examination of this nodule confirmed the diagnosis of bronchioloalveolar carcinoma (BAC). Segmentectomy of RS8 with lower mediastinal node dissection (ND2a-1) was performed. The intersegmental plane was identified using the intersegmental veins as landmarks and the demarcation between the resected (inflated) and preserved (collapsed) lungs. Electrocautery at 70 watts was used to divide the intersegmental plane. A vessel sealing system was used to seal and cut the pulmonary arteries. Postoperative histopathological examination revealed that the tumor was T1aN0M0 BAC, and the minimal distance between the surgical margin and the tumor edge was 15 mm. The patient was discharged from hospital on postoperative day 5 without any complications.

Surgical treatment for aortic coarctation with chronic type B dissection: report of a case.

The aim of this paper is to report a rare case of aortic coarctation with type B aortic dissection. A 37 year-old man had sudden, intense back pain. Enhanced computed tomography revealed aortic coarctation (CoA) at the proximal descending aorta and acute type B aortic dissection just distal to the CoA. The dissecting, descending aortic aneurysm had expanded to a maximal diameter of 52 mm. The aortic coarctation was resected and then the descending aorta was replaced with prosthetic grafts in an uneventful procedure. Surgical repair resulted in a good outcome.

Domains 16 and 17 of tropoelastin in elastic fibre formation.

Naturally occurring mutations are useful in identifying domains that are important for protein function. We studied a mutation in the elastin gene, 800-3G>C, a common disease allele for SVAS (supravalvular aortic stenosis). We showed in primary skin fibroblasts from two different SVAS families that this mutation causes skipping of exons 16-17 and results in a stable mRNA. Tropoelastin lacking domains 16-17 (Delta16-17) was synthesized efficiently and secreted by transfected retinal pigment epithelium cells, but showed the deficient deposition into the extracellular matrix compared with normal as demonstrated by immunofluorescent staining and desmosine assays. Solid-phase binding assays indicated normal molecular interaction of Delta16-17 with fibrillin-1 and fibulin-5. However, self-association of Delta16-17 was diminished as shown by an elevated coacervation temperature. Moreover, negative staining electron microscopy confirmed that Delta16-17 was deficient in forming fibrillar polymers. Domain 16 has high homology with domain 30, which can form a beta-sheet structure facilitating fibre formation. Taken together, we conclude that domains 16-17 are important for self-association of tropoelastin and elastic fibre formation. This study is the first to discover that domains of elastin play an essential role in elastic fibre formation by facilitating homotypic interactions.

Development of a new in vitro model of elastic fiber assembly in human pigmented epithelial cells.

OBJECTIVES: We developed an in vitro model of elastic fiber assembly that provides a comparison of the efficiency of different tropoelastin molecules to organize into fibers. DESIGN AND METHODS: Recombinant tropoelastin was added to ARPE-19 cell culture medium. The elastic fiber assembly was evaluated by immunofluorescence staining, the quantitative analysis of cross-linking amino acids, and semi-quantitative analysis of matrix-associated tropoelastin. RESULTS: We confirmed that ARPE-19 cells express fibrillin-containing microfibrils and lysyl oxidase, but they do not express tropoelastin. Immunofluorescence staining showed a dose- and time-dependent increase in the extracellular matrix. The quantity of cross-linking amino acids and matrix-associated tropoelastin also increased together with the matrix-associated elastin. Moreover, the analysis of a radioimmunoprecipitation assay (RIPA) buffer-soluble fraction indicated that tropoelastin interacted with microfibrils and cross-linked elastin was detected as a super molecular complex. CONCLUSION: These observations indicate that this in vitro model is especially useful for the analysis of mechanisms of elastic fiber formation.