Mini open stent grafting with half sternotomy for aortic arch aneurysm.

BACKGROUND: Open stent grafting is an alternative of graft replacement and thoracic endovascular aortic repair for aortic arch aneurysm. We have performed open stent grafting with half sternotomy (mini-OSG) to reduce in-hospital stay and recovery time of patients and herein report seven cases of mini-OSG for aortic aneurysm and dissection. CASE PRESENTATION: The patients' mean age was 66 years. Cardiopulmonary bypass was performed conventionally, and an open stent graft was inserted via an aortotomy on the aortic arch during circulatory arrest. No mortality occurred. The mean operation time was 387 min, and the mean blood loss was 587 ml. The patients were weaned from the ventilator 7.1 h postoperatively. No pseudoaneurysm or endoleakage was observed during the 2- to 20-month follow-up. CONCLUSIONS: Mini-OSG might be less invasive, although further studies and intensive follow-up are needed.

[Successful Treatment with Aortic Stent Graft and Transcatheter Embolization for Bronchial Artery Aneurysm].

We report a case of bronchial artery aneurysm (BAA) successfully treated with a combination of transcatheter embolization and stent graft. A 50-year-old woman was referred to our hospital for further examination of a hemispherical bulging lesion on the middle esophagus detected by gastroscopy. Computed tomography (CT) revealed BAA with a 15 mm-diameter arising from the descending aorta on the left side of the esophagus. We performed transcatheter embolization combined with a stent graft because of a short neck. Postoperative course was uneventful. Follow-up CT showed complete isolation of the blood flow into the BAA. BAA is rare and often found incidentally by diagnostic imaging as shown in our case. Prompt treatment with complete isolation of blood inflow is required because the rupture of BAA is life-threatening.

Open stent graft repair with upper-half Sternotomy for blunt thoracic aortic injury: a case report.

BACKGROUND: Thoracic endovascular aortic repair is now widely applied to the treatment of blunt aortic injury. However, its long-term outcomes remain unclear. Endoleakage and migration might occur in the long term, especially when younger patients undergo endovascular aortic repair. In open stent grafting, the proximal end of the open stent graft is directly sutured to the native aorta, which may reduce the risk of endoleakage and migration. We applied open stent grafting to the treatment of blunt aortic injury in the subacute phase and herein report the patient's clinical course. CASE PRESENTATION: A 20-year-old man with a developmental disorder collided with a steel tower while skiing. He was transferred to our hospital by helicopter. X-ray examination and computed tomography revealed fractures of left humeral head and femoral neck and aortic isthmus dissection. We did not perform an acute-phase operation because of the presence of multiple trauma and instead performed open stent grafting with an upper-half sternotomy 42 days after the injury. He recovered uneventfully without psychological problems other than his preexisting developmental disorder. No endoleakage or aneurysm was observed during an 18-month follow-up period. CONCLUSIONS: Open stent grafting might be an alternative to open surgery and thoracic endovascular aortic repair for blunt chest trauma, although intensive follow-up is needed.

Hemolytic anemia caused by aortic flap and inversion of felt strip after ascending aorta replacement.

BACKGROUNDS: Hemolysis related to a kinked prosthetic graft or inner felt strip is a very rare complication after aortic surgery. We describe herein a case of hemolytic anemia that developed due to aortic flap of the dissection and inversion of an inner felt strip that was applied at the proximal anastomosis of a replaced ascending aorta 10 years previously. CASE PRESENTATION: A 74-year-old woman presented with consistent hemolytic anemia 10 years after replacement of the ascending aorta to treat Stanford type A acute aortic dissection. The cause of hemolysis was attributed to mechanical injury of red blood cells at a site of stenosis caused by aortic flap of the dissection and inversion of the felt strip used for the proximal anastomosis. Repeated resection of the strip and graft replacement of the ascending aorta resolved this problem. CONCLUSIONS: We considered that blood flow disrupted by a jet of blood at the site of the proximal inner felt strip was the cause of severe hemolysis, we describe rare hemolytic anemia at the site of aortic flap and inverted felt strip after replacement of the ascending aorta.

[Graft Replacement for Adult Aortic Coarctation].

Case 1:a 47-year-old woman who complained of sweating, finger tremor, and chest pain was diagnosed with coarctation of the aorta and hyperthyroidism. She had been diagnosed with hypertension at 25 years of age but had not undergone further examination. Graft replacement was performed without cardiopulmonary or temporary bypass. Case 2:a 30-year-old woman was diagnosed with coarctation during infertility treatment. Although health screening had revealed hypertension 8 years previously, no further assessment took place. She underwent graft replacement with partial cardiopulmonary bypass. In both cases, we conducted a clamp test to decide whether cardiopulmonary or partial bypass was necessary for graft replacement. Blood pressure discrepancy between upper and lower extremities disappeared immediately after surgery, and no ischemic complications were observed. Hypertension in young adults should prompt further scrutiny for anatomical disorders such as coarctation. A clamp test is considered helpful regarding the surgical approach to graft replacement for coarctation.

[Acute type A aortic dissection with Birt-Hogg-Dubé syndrome; report of a case].

We describe a 76-year-old woman with cardiac tamponade who was admitted to our hospital. She underwent ascending and partial arch aortic replacement to treat acute type A aortic dissection. However, postoperative respiratory failure developed and a chest X-ray revealed right lung pneumothorax. The lung was finally expanded after difficulties with prolonged tube drainage. Chest computed tomography(CT) showed multiple cystic changes in the bilateral lungs. Her sister and her daughter also had a history of spontaneous pneumothorax. We finally diagnosed Birt-Hogg-Dube syndrome after deoxyribonucleic asid(DNA)sequencing of folliculin( FLCN) gene.

Surgical strategy for impending rupture of an infected anastomotic pseudoaneurysm of the aorta 9 years after a Bentall procedure: radical surgery involving en bloc resection of the infected sternum, pseudoaneurysm, and artificial vascular graft.

Infection of the sternum and anterior mediastinitis after open heart surgery are serious complications that are intractable with high case fatality rates. Frequently, infection spreads to an artificial foreign body in the mediastinum, causing difficulties with treatment. We report a case of infected pseudoaneurysm of the aorta at the anastomotic site of the artificial vascular graft. The infection spread from sternal osteomyelitis 9 years 5 months after aortic root replacement (Bentall procedure) for acute aortic dissection. We performed radical surgery that included en bloc resection of the infected sternum, pseudoaneurysm, and artificial vascular graft, with successful results. We report here the surgical strategy including the approach.

2,3-butanedione monoxime affects cystic fibrosis transmembrane conductance regulator channel function through phosphorylation-dependent and phosphorylation-independent mechanisms: the role of bilayer material properties.

2,3-Butanedione monoxime (BDM) is widely believed to act as a chemical phosphatase. We therefore examined the effects of BDM on the cystic fibrosis transmembrane regulator (CFTR) Cl(-) channel, which is regulated by phosphorylation in a complex manner. In guinea pig ventricular myocytes, forskolin-activated whole-cell CFTR currents responded biphasically to external 20 mM BDM: a rapid approximately 2-fold current activation was followed by a slower (tau approximately 20 s) inhibition (to approximately 20% of control). The inhibitory response was abolished by intracellular dialysis with the phosphatase inhibitor microcystin, suggesting involvement of endogenous phosphatases. The BDM-induced activation was studied further in Xenopus laevis oocytes expressing human epithelial CFTR. The concentration for half-maximal BDM activation (K(0.5)) was state-dependent, approximately 2 mM for highly and approximately 20 mM for partially phosphorylated channels, suggesting a modulated receptor mechanism. Because BDM modulates many different membrane proteins with similar K(0.5) values, we tested whether BDM could alter protein function by altering lipid bilayer properties rather than by direct BDM-protein interactions. Using gramicidin channels of different lengths (different channel-bilayer hydrophobic mismatch) as reporters of bilayer stiffness, we found that BDM increases channel appearance rates and lifetimes (reduces bilayer stiffness). At 20 mM BDM, the appearance rates increase approximately 4-fold (for the longer, 15 residues/monomer, channels) to approximately 10-fold (for the shorter, 13 residues/monomer channels); the lifetimes increase approximately 50% independently of channel length. BDM thus reduces the energetic cost of bilayer deformation, an effect that may underlie the effects of BDM on CFTR and other membrane proteins; the state-dependent changes in K(0.5) are consistent with such a bilayer-mediated mechanism.

Cardiac angiosarcoma with right atrial perforation and cardiac tamponade.

Primary cardiac angiosarcoma is a rare tumor associated with a poor prognosis. We report a case of a 59-year-old woman with right atrial angiosarcoma presenting with cardiac tamponade due to right atrial perforation. She underwent urgent surgical resection of the tumor. However, the patient died 68 days after surgery due to local recurrence. An effective treatment for cardiac angiosarcoma has not yet been established. However, more aggressive treatment with a combination of surgery, radiation, chemotherapy and IL-2 should be considered.

Perioperative coronary artery spasm in off-pump coronary artery bypass grafting and its possible relation with perioperative hypomagnesemia.

PURPOSE: We experienced 3 cases of serious perioperative coronary artery spasm in off-pump coronary artery bypass grafting (OPCAB). In consideration of the causes, we directed our attention to hypomagnesemia, one of the triggers of coronary artery spasm. This study was performed to confirm the tendency to hypomagnesemia in OPCAB. METHODS: First, we report 3 patients having severe coronary artery spasm immediately after OPCAB with consideration of the causes. Second, serial magnesium (Mg) value (xylidyl blue method, normal 1.9-3.1 mg/dl) was measured in 45 consecutive patients with OPCAB between April and October 2002, 1) before starting the operation, and 2) after the patient's entrance into the intensive care unit. RESULTS: Preoperative and postoperative values of Mg (mg/dl) were 2.1+/-0.3, 1.7+/-0.3, respectively (p < 0.01). Postoperative incidence of hypomagnesemia was as high as 89% of the patients (40 out of 45 patients). In this study and thereafter, we corrected hypomagnesemia with magnesium sulfate during and after OPCAB, and no perioperative coronary artery spasm occurred. CONCLUSION: Hypomagnesemia, one of the triggers of coronary artery spasm, is very common in OPCAB. We strongly recommend the correction of hypomagnesemia during and after OPCAB for the prevention of perioperative coronary artery spasm.

Cardiac rupture after catheter ablation procedure.

We describe a patient in whom cardiac tamponade developed owing to left ventricular rupture after a catheter ablation procedure. Rapid surgical exploration and use of cardiopulmonary bypass facilitated safe repair of the injury site and survival of the patient without complications.

Successful resection of cardiac metastatic liposarcoma extending into the SVC, right atrium, and right ventricle.

Cardiac metastatic liposarcoma is a rare tumor. We report a case of successful resection of a cardiac metastatic liposarcoma extending into the superior vena cava (SVC), right atrium, and right ventricle. Using cardiopulmonary bypass (CPB) by venous cannulation of the upper portion of the SVC and inferior vena cava (IVC), the intracardiac tumor was completely resected. Surgical resection with the addition of radiotherapy prolonged the patient's life.

Surgery for acute type A aortic dissection in pregnant patients with Marfan syndrome.

OBJECTIVE: Acute type A aortic dissection during pregnancy can be fatal to both the mother and the fetus. The goal of the present study was to characterize the prevalence, treatment and outcomes of this dangerous condition in an effort to determine optimal management. METHODS: A retrospective study was conducted using data from four Marfan patients with acute type A aortic dissection during pregnancy at our institution between 1991 and 2003. RESULTS: The mean gestational period at the time of operative repair was 31 weeks, with a range of 26-34 weeks, and the aortic root diameter ranged from 35 to 85 mm. Two of the four patients underwent a combined operation with cesarean section followed by aortic repair. One patient underwent operative aortic repair following spontaneous delivery. The final patient underwent aortic repair with the fetus remaining in situ. Median sternotomy and cardiopulmonary bypass were established via the femoral artery with direct right atria drainage and left atrial venting in all patients. Composite graft replacement combined with re-implantation of the coronary artery and aortic valve replacement were performed in three patients, and aortic valve replacement with coronary artery bypass grafting of the right coronary artery was performed in one patient. Three of four patients underwent aortic arch repair utilizing antegrade cerebral perfusion and deep hypothermia with total circulatory arrest. The patient that underwent operative correction with the fetus remaining in situ experienced fetal demise with miscarriage just after cardiac surgery, and the patient died 4 days later secondary to disseminated intravascular coagulation and multi-organ failure. The remaining three cases recovered uneventfully, and the mothers and babies were discharged in good condition. CONCLUSIONS: Based on these data, we advocate cesarean section with concomitant aortic repair for patients with Marfan syndrome and acute type A aortic dissection during pregnancy. Minimization of deep hypothermic circulatory arrest time is also recommended for cases in which the fetus remains in situ.

Successful surgical treatment for acute aortic dissection in pregnancy with Marfan's syndrome.

A 34-year-old pregnant woman with Marfan's syndrome in the 34th week of gestation was diagnosed with acute DeBakey type I aortic dissection. Immediately after cesarean section, she underwent emergent operation of combined total aortic arch and aortic root replacement using cardiopulmonary bypass, deep hypothermia and antegrade cerebral perfusion. Both maternal and fetal outcomes were good and uneventful. Pregnancy increases the risk of aortic dissection especially for patients with Marfan's syndrome. Moreover it should be noted that cardiac surgery using cardiopulmonary bypass and deep hypothermia generally results in fetal loss. If fetal maturity can be confirmed as in our case, cesarean section should be done before cardiovascular surgery. We describe here a case of successful operation for mother and infant at the 34th week of gestation.

Surgical treatment of pseudoaneurysm of the sinus of valsalva after aortic valve replacement for active infective endocarditis.

Pseudoaneurysm is an uncommon and serious complication of infective endocarditis (IE). It is often fatal because of its rapid progress, high rates of rupture and recurrence, and worsening effects on the systemic condition. We report the rare case of a patient who developed a pseudoaneurysm of the sinus of Valsalva two months after emergency aortic valve replacement for active IE. At the previous operation, we had directly closed a small fistulous hole in the non-coronary sinus of Valsalva using two mattress sutures with autologous pericardial pledgets, because the tissue surrounding the hole did not appear to be infected on visual inspection. A pseudoaneurysm developed from this portion due to detachment of sutures. If the fistula had been completely resected during the first surgery instead of performing a simple closure, the pseudoaneurysm of the sinus of Valsalva would not have formed. However, the primary aim of the first emergency surgery was to spare the life of a critically ill patient. In the second surgery, the pseudoaneurysm was completely resected with the aortic wall--including the non-coronary sinus of Valsalva and the communicating hole. Then, patch plasty of the non-Valsalva sinus was successfully performed.

New application method of fibrin glue for more effective hemostasis in cardiovascular surgery: rub-and-spray method.

OBJECTIVE: This study was performed to determine the most effective application method of fibrin glue as a hemostatic sealant in cardiovascular surgery. METHODS: The effectiveness of fibrin glue as a hemostatic sealant was compared between 4 methods of application; dripping, spray, spray-and-rub, and rub-and-spray methods. I. In vitro 'burst pressure' was measured in fibrin glue-sealed needle holes of polytetrafluoroethylene (PTFE) graft in each method. II. Fibrin glue-sealed needle holes of PTFE grafts implanted between an abdominal aorta and iliac arteries of a pig was microscopically examined to determine the effectiveness of fibrin glue sealing in each method. RESULTS: I. Burst pressures were 24.1 +/- 7.9 mmHg in dripping, 98.1 +/- 35.4 mmHg in spray, 140.8 +/- 34.8 mmHg in spray-and-rub and 206.7 +/- 26.1 mmHg in rub-and-spray method (statistically significant, p<0.01, between each method). II. Microscopically, no fibrin glue remained on the external surface of the PTFE graft in the dripping method. Fibrin glue plugged 1/3 or 2/3 of the depth of the needle hole in the spray method and spray-and-rub methods respectively. In the rub-and-spray method, fibrin glue covered the needle hole over the external surface of the graft, completely plugged the needle hole to its whole depth, leaving no spaces where blood came into the needle hole. CONCLUSION: The rub-and-spray method of fibrin glue application revealed the strongest sealing and hemostatic effects, and can be safely and effectively used for hemostasis in cardiovascular surgery that requires systemic heparinization or prolonged extracorporeal circulation.

Suppression of acute and chronic rejection by hepatocyte growth factor in a murine model of cardiac transplantation: induction of tolerance and prevention of cardiac allograft vasculopathy.

BACKGROUND: Although treatment with immunosuppressive agents has contributed to overcoming acute rejection and improving the midterm survival of transplanted hearts, cardiac allograft vasculopathy (CAV) has remained the main cause of primary graft failure. Recent approaches have shown that hepatocyte growth factor (HGF) exhibits cardiotrophic functions. We therefore addressed whether HGF would regulate acute and chronic rejection in cardiac transplantation. METHODS AND RESULTS: We used a murine heterotopic cardiac transplantation model between fully incompatible strains and administered 500 microg x kg(-1) x d(-1) HGF during the initial 14 days after transplantation. The HGF-treated allografts showed significantly prolonged survival (42.3+/-4.1 days, P<0.001) compared with the controls (11.1+/-0.6 days), with tolerance induction in 47.4%. Histopathologically, the number of infiltrating cells was significantly decreased and myocardial necrosis was less prominent with a reduction of apoptosis in the allografts by HGF treatment during acute rejection. In the long-term surviving allografts, HGF significantly inhibited the development of CAV and interstitial fibrosis. With respect to intragraft cytokine mRNA expression, HGF treatment reduced the early expression of interferon-gamma and enhanced the expression of transforming growth factor-beta1 during the acute phase and of interleukin-10 continuously through the acute phase to the chronic phase. CONCLUSIONS: Our findings demonstrate that HGF can prolong the survival of allografts by its cardioprotective and immunomodulative potencies. Thus, HGF administration may constitute a new therapeutic approach to preventing cardiac graft failure that has not been overcome by conventional immunosuppressive agents.

Successful repair of aberrant right subclavian artery aneurysm combined with bicuspid aortic valve through a median sternotomy.

We report a case of a successfully repaired aberrant right subclavian artery aneurysm combined with bicuspid aortic valve using a multibranched vascular prosthesis. Approaching solely through a median sternotomy under cardiopulmonary bypass, hypothermic circulatory arrest, and selective cerebral perfusion, we performed a successful single-stage correction by aortic valve replacement, resection of aneurysm, and reconstruction of the right subclavian artery.

Transapical aortic cannulation using a deep hypothermic procedure through a left thoracotomy for acute traumatic aortic rupture.

We describe a transapical aortic cannulation procedure through a left thoracotomy for a case of acute traumatic aortic rupture. A 26-year-old man was involved in a motor vehicle accident and admitted in a state of hypovolemic shock. Chest computed tomography findings revealed a rupture of the proximal portion of the descending aorta and a massive hematoma around the aorta extending into the thoracic cavity. Under hypothermic circulatory arrest, he underwent an emergency graft replacement through a left thoracotomy. We used transapical aortic cannulation together with femoral cannulation, in order to avoid malperfusion of the brain and upper body that can occur as a result of retrograde perfusion. The postoperative outcome was favorable. Transapical cannulation is a useful alternative for hypothermic aortic operations through a left thoracotomy.

[Effects of rice cleaning and cooking process on the residues of flutolanil, fenobucarb, silafluofen and buprofezin in rice].

We studied the effect of cleaning and cooking on the residues of flutolanil, fenobucarb, silafluofen and buprofezin in rice. The rice had been sprayed in a paddy field in Wakayama city, with 3 kinds of pesticide application protocols: spraying once at the usual concentration of pesticides, repeated spraying (3 times) with the usual concentration of pesticides and spraying once with 3 times the usual concentration of pesticides. The residue levels of pesticide decreased during the rice cleaning process. Silafluofen, which has a higher log Pow value, remained in the hull of the rice. Fenobucarb, which has a lower log Pow value, penetrated inside the rice. The residue concentration of pesticide in polished rice was higher than that in pre-washed rice processed ready for cooking. During the cooking procedure, the reduction of pesticides in polished rice was higher than that in brown rice.