Multidisciplinary surgical approach for renal cell carcinoma with inferior vena cava tumor thrombus.

PURPOSES: The optimal surgical management of renal cell carcinoma with tumor thrombus within the inferior vena cava (IVC) remains to be clarified. METHODS: Sixteen consecutive cases were reviewed. Incision, the IVC clamping position, and the venous drainage procedure were modified according to the tumor thrombus extension level: level I or II (below the hepatic vein, n = 8), level III (above the hepatic vein but below the right atrium, n = 5), and level IV (extending into the right atrium, n = 3). RESULTS: For level I or II, resection could be simply achieved by clamping the IVC below the hepatic vein, without hemodynamic collapse. For level III, clamping the IVC above the hepatic vein and the hepatoduodenal ligament was required. Venous drainage from the lower body (cannulation to distal IVC) and portal system (cannulation to ileocolic vein) were applied. When opening the IVC, the significant backflow was controlled using cardiopulmonary bypass with drop-in suckers. For level IV, median sternotomy, exposure of the right atrium, and cardiopulmonary bypass were mandatory. With the combination of these approaches, the perioperative mortality rate was 0% and the 5-year overall survival rate was 52%. CONCLUSIONS: A multidisciplinary surgical approach is essential, especially for level III and IV cases.

Spinal cord injury following aortic arch replacement.

PURPOSE: Postoperative spinal cord injury is a devastating complication after aortic arch replacement. The purpose of this study was to determine the predictors of this complication. METHODS: A group of 254 consecutive patients undergoing aortic arch replacement via median sternotomy, with (n = 78) or without (n = 176) extended replacement of the upper descending aorta, were included in a risk analysis. The frozen elephant trunk technique was used in 46 patients. The patients' atherothrombotic lesions (extensive intimal thickening of > 4 mm) were identified from computed tomography images. RESULTS: Complete paraplegia (n = 7) and incomplete paraparesis (n = 4) occurred immediately after the operation (permanent spinal cord injury rate, 1.97%; transient spinal cord injury rate, 2.36%). A multivariable logistic regression analysis identified the use of the frozen elephant trunk technique (odds ratio 36.3), previous repair of thoracoabdominal aorta or descending aorta (odds ratio 29.4), proximal atherothrombotic aorta (odds ratio 9.6), chronic obstructive lung disease (odds ratio 7.1) and old age (odds ratio 1.1) as predictors of spinal cord injury (p < 0.0001, area under curve 0.93). CONCLUSIONS: Spinal cord injury occurs with a non-negligible incidence following aortic arch replacement. The full objective assessment of the morphology of the whole aorta and the recognition of the risk factors are mandatory.

[Intractable Atrial Arrhythmia after Maze Procedure].

Maze procedure has achieved high cure rates and become the surgical golden standard for the treatment of atrial fibrillation. But, atrial arrhythmia after maze procedure is often persistent and drug-resistant. In these cases, diagnosis by electrophysiological study (EPS) and treatment by catheter ablation (ABL) are useful. In our hospital, maze procedure has been actively performed for mitral valve surgery with atrial arrhythmia. We examined the cases that required ABL after maze procedure in our hospital. We reported 2 such typical cases where ablation of cavo-tricuspid isthmus line (CTI) in the right atrium and left superior pulmonary vein-left atrial appendage space( LSPV-LAA ridge) in the left atrium was effective.

[Severe Coronary Artery Spasm after Coronary Artery Bypass Grafting;Report of a Case].

Coronary artery spasm after coronary artery bypass grafting(CABG) is rare and often fatal. There is no established treatment for perioperative coronary spasm because of the rare and not fully understood complications. We report a 67-year-old male, who experienced perioperative spasm of native coronary arteries and the left thoracic artery graft following CABG. Several transcatheter intracoronary injections of isosorbide sulfate failed to relieve the spasm completely. After 5 days' circulatory support with intra-aortic balloon pumping, the cardiac function improved and the patient recovered. Echocardiography performed before discharge showed decreased left ventricular systolic function with apical akinesis. Postoperative coronary angiography revealed 4 of the 5 grafts were patent.

[Fifteen-year Follow-up of a Patient with Aortitis, Treated by Sino-tubular Junction Plication Using a Prosthetic Tube Graft for Aortic Regurgitation;Report of a Case].

A 43-year-old woman was diagnosed with aortitis associated with mild aortic regurgitation (AR) at the age of 25, which advanced to a severe grade requiring surgical treatment at age 28. Dilation of the sinotubular junction (STJ) was treated with ascending aortic replacement (Hemashield Gold 24 mm), which reduced AR from severe to mild. The patient conceived 9 years later and delivered a baby by cesarean section at 38 weeks of gestation. By appropriate control of inflammation with steroid, neither deterioration of the aortic valve nor cardiac function has been noted during the 15 years of follow-up after surgery.

[Incomplete Surgical Resection of a Right Ventricular Hemangioma with Asymptomatic Gradual Enlargement for more than a Decade;Report of a Case].

We encountered a case of a cardiac hemangioma protruding into the inner cavity of the right ventricle from the right ventricular free wall. The tumor gradually enlarged over 11 years (from 35 mm to 78mm) without presenting any symptoms. However, when it extended to the right ventricular outflow tract, non-sustained ventricular tachycardia occurred, and emergency surgery was required. The tumor was diagnosed as a cavernous benign hemangioma. Complete resection was not possible, and the part involving the right ventricle remained. This residual tumor caused postoperative ventricular arrhythmia, and an implantable cardioverter defibrillator was required. We concluded that non-surgically treated cardiac hemangiomas carry the risk of non-resectability, regardless of malignancy.

[Aortic Valve Replacement of Quadricuspid Valve with Regurgitation].

Congenital quadricuspid aortic valve is a very rare malformation. In most cases it has been found incidentally at aortic valve surgery or at autopsy. It frequently causes aortic regurgitation, which may become manifest in adulthood and require surgical treatment. We reported 4 cases of aortic regurgitation with quadricuspid aortic valve. In all cases, aortic valve replacement was preformed with prosthetic valve, and their postoperative courses were uneventful. Two were Hurwitz's classification type b, one was type a and the last patient was type c. Although quadricuspid aortic valve is a rare anomaly, its potential for severe valve failure in adulthood should be kept in mind.

Risk-adjusted mortality rate cumulative sum analysis based on the Japan SCORE represents a learning curve in mitral valve reparative surgery.

PURPOSE: We calculated the cumulative sum analysis of an individual surgical learning curve for mitral valve reconstructive surgery to monitor quality control. METHODS: Between April 2003 and March 2009, 25 consecutive patients underwent mitral valve reconstructive surgery for mitral regurgitation (MR). All operations were performed by a single surgeon. We analyzed the operative variables, mortality, and major morbidities and calculated the learning curve, using descriptive statistics and cumulative sum analysis based on the Japan SCORE calculator. RESULTS: In this series, the Japan SCORE calculator predicted a 30-day operative mortality rate of 3.07 ± 3.48 % and a 30-day operative mortality and morbidity rate of 14.9 ± 9.58 %s. In reality, there was no operative or in-hospital death and the major postoperative morbidity rate was 6.0 % (two patients). The risk-adjusted cumulative sum analysis revealed that the learning curve for mortality and morbidity shifted downward below the lower confident interval for all the patients, on completion of mitral valve repair. Coefficient analysis revealed a significant negative correlation between the aortic cross-clamp time and the cardiopulmonary time and case load. There was no correlation between the operation time and the case load. CONCLUSIONS: Routine reconstructive mitral valve surgery for MR can be performed at the professionally permissive level from the beginning, even in low-volume case loads.

Collagen type IV-specific tripeptides for selective adhesion of endothelial and smooth muscle cells.

Controlling the balance of endothelial cells (ECs) and smooth muscle cells (SMCs) in blood vessels is critically important to minimize the risk associated with vascular implants. Extracellular matrix (ECM) plays a key role in controlling the cellular balance, suggesting a promising source of cell-selective peptides. To obtain EC- or SMC-selective peptides, we start by highlighting sequence differences found among ECM molecules as enriched targets for cell-selective peptides. We explored the EC- or SMC-selective performance of tripeptides that are specifically enriched only in collagen type IV, but not in types I, II, III, and V. Collagen type IV was chosen since it is the major ECM in the basement membrane of blood vessels, which separates ECs and SMCs. Among 114 collagen type IV-derived tripeptides pre-screened from in silico analysis, 22 peptides (19%) were found to promote cell-selective adhesion, as determined by peptide array. One of the best performing EC-selective peptides (Cys-Ala-Gly (CAG)) was mixed into an electrospun fine-fiber, a vascular graft material, for practical application. Compared to unmodified fiber, the CAG containing fiber surface was found to enhance adhesion of ECs (+190%) while limiting SMCs (-20%). These results are not only consistent with the hypothesis of ECM as a source of cell selective peptides, but also suggest a new genre of EC- or SMC-selective peptides for tissue engineering applications. Collectively, these findings favorably support the screening approach used to discover new peptides for these purposes.

Long-term results of tissue-engineered small-caliber vascular grafts in a rat carotid arterial replacement model.

The concept of tissue engineered small-caliber vascular grafts (TE-SCVGs) is theoretically ideal. In this study, we evaluated the long-term (more than 1 year) course of TE-SCVGs using a rat carotid arterial replacement model. We fabricated a TE-SCVG scaffold (0.7 mm in diameter) with electrospun nano-scale fibers. Poly-ε-caprolactone was used as a biodegradable polymer. These artificial vessels were then used in carotid arterial replacement performed on Sprague-Dawley rats. The implanted grafts were removed at an early phase (1, 2, 6 weeks), middle phase (12, 24 weeks), and late phase (48, 72 weeks) after implantation. Twenty-nine patent grafts from among the 40 implanted grafts (patency 72.5 %) could be evaluated. No aneurysm formation was observed during the follow-up period. Endothelial cells positive for immunostaining with von Willebrand factor were found to be already attached to the inner surface of the TE-SCVGs in the early phase. The percentage of smooth muscle cell specific marker (α-smooth muscle actin and calponin with fluorescent immunostaining) positive cells, which seemed to be mesenchymal cells in the graft wall, increased with time, while, in contrast, the scaffold material decreased. Even after 72 weeks, however, although the scaffold material had degraded, it had not disappeared completely. These results show that the novel TE-SCVGs we developed were still functioning in the rat carotid arterial circulation after more than 1 year. However, further investigations will be required with regard to regeneration of the SMC layer and the complete degradation of graft materials.

Pathogenesis of paravalvular leakage as a complication occurring in the late phase after surgery.

Paravalvular leakage (PVL) remains an unavoidable late complication after valve surgery. We indicate surgery only cases with progressive congestive heart failure and/or hemolytic anemia. We review our clinical experiences of PVL surgery. Between 1992 and 2009 we experienced 8 cases of aortic PVL-6 subjects after primary aortic valve replacement (AVR) and 2 subjects after re-AVR-and 10 subjects with mitral PVL-5 cases after primary mitral valve replacement (MVR) and 5 cases after re-MVR. Mitral PVL began in the later phases after surgery and had more severe symptoms, because of heart failure and/or hemolytic anemia, than aortic PVL. Aortic PVL occurred more frequently because of laxation of sutured threads without frequent sites. Conversely, mitral PVL was mainly caused by cutting annulus tissue around the anterior commisurae after primary MVR, and by a valve-on-valve structure on the middle scallop of the posterior leaflet or circumferentially after re-MVR. All operations were performed safely and all patients were discharged uneventfully. No cases experienced recurrence of PVL in the follow-up period. The symptoms of PVL became exacerbated, and our surgical indications based on these symptoms were validated. Valve-on-valve replacement, which was a major cause of PVL after re-MVR, should be avoided in a re-MVR procedure. Cautious follow-up is necessary, even in the late phase after surgery, especially for patients who have undergone MVR.

[Primary cardiac angiosarcoma in the left atrium with adrenal metastasis; report of a case].

We encountered a 61-year-old woman with primary cardiac angiosarcoma in the left atrium. On echocardiography, the tumor extended into the atrial septum and mitral valve, and mitral valve stenosis and regurgitation were significant. We resected the tumor protruding into left atrium, and affecting mitral valve. The surgical procedure was not radical, but on postoperative echocardiography, function of the mitral valve was improved. Three months later, elevation of her right diaphragma was observed on chest X-ray and a giant adrenal tumor was detected by magnetic resonance imaging. Tumor biopsy indicated that this tumor was adrenal metastasis from cardiac angiosarcoma. In addition, echocardiography showed the recurrence of angiosarcoma in the left atrium and the presence of mitral stenosis and regurgitation. She died of heart failure 185 days postoperatively.

A case of floating thrombus in the ascending aorta that caused recurrent peripheral arterial embolic events.

We report the case of a 62-year-old man with recurrent arterial embolisms to his arms caused by a thrombosis of the ascending aorta. He had developed a left brachial artery embolism 8 years previously, but presented with a right brachial artery embolus on this occasion. A clot-like mass was seen in the ascending aorta on computed tomography without significant atherosclerosis. Magnetic resonance imaging identified multiple asymptomatic cerebral infarctions. Therefore, we surgically removed the thrombus in the ascending aorta, which was an organized fibrin clot. Pathologically, atherosclerosis and plaque formation were evident at the intima where the clot attached. Clot formation was considered to be due to local arteriosclerosis. We report a case of thrombosis of the ascending aorta causing multiple and recurrent arterial embolisms. The patient had no evidence of coagulation disorders, and arteriosclerotic risk factors such as hypertension, diabetes mellitus, and dyslipidemia were absent. Thus, thrombosis may develop in patients without traditional risk factors. .

Novel small-caliber vascular grafts with trimeric Peptide for acceleration of endothelialization.

BACKGROUND: Both rapid endothelialization and the prevention of intimal hyperplasia are essential to improve the patency of small-caliber vascular grafts (SCVGs). Using the peptide array based screening system, we identified the peptide CAG (cysteine-alanine-glycine), which has a high affinity for endothelial cells and a low adhesive property for smooth muscle cells (SMCs). In this article, we report an in vivo analysis of novel vascular grafts that were constructed with a biodegradable polymer (poly-ε-caprolactone [PCL]) containing CAG peptide. METHODS: The novel SCVG, which measured 0.7 mm in diameter and 7 mm in length, was fabricated using the electrospinning technique. Carotid arterial replacement was performed on Sprague-Dawley rats using SCVGs with (group CAG) or without CAG (group C). Histologic and biochemical assessments were performed at 1, 2, and 6 weeks after implantation. RESULTS: The ratio of endothelialization was significantly higher in group CAG compared with group C (CAG versus C, 64.4±20.0% versus 42.1±8.9% at 1 week; p=0.017; 98.2±2.3% versus 72.7±12.9% at 2 weeks; p=0.001; and 97.4±4.6% versus 76.7±5.4% at 6 weeks; p<0.001). Additionally, Western blot analysis showed that the level of endothelial nitric oxide synthase (eNOS) at 1 week in group CAG was significantly higher than that in group C (CAG versus C, 1.20±0.37 versus 0.34±0.16; p=0.013), and that α-smooth muscle actin (ASMA) at 6 weeks in group CAG was significantly lower than that in group C (CAG versus C, 0.89±0.06 versus 1.25±0.22; p=0.04). CONCLUSIONS: The graft with CAG promoted rapid endothelialization and the potential for inhibition of intimal hyperplasia.