[Lipomatous Hypertrophy of the Interatrial Septum Preoperatively Misdiagnosed as Right Atrial Lipoma].

A 73-year-old man with a right atrial tumor and a distal aortic arch aneurysm was scheduled for tumor resection and total arch replacement (TAR). Although the tumor was diagnosed as an intraatrial lipoma preoperatively, it could not be differentiated from an infiltrating lipoma on the basis of intraoperative pathological examination. We decided to completely excise the tumor. However, we found intraoperatively that the tumor was contiguous with the epicardial fat tissue of the heart, strongly suggesting a lipomatous hypertrophy of the interatrial septum (LHIS). Thus, we discontinued the resection, reconstructed the atrial septum and right atrial wall, and performed TAR with a frozen elephant trunk technique. Although the patient required temporary continuous hemodiafiltration because of his preoperative renal dysfunction, he was discharged 30 days postoperatively. If LHIS was the preoperative diagnosis, only an incisional biopsy was needed for diagnosing this case. However, LHIS is quite rare in Japan. Therefore, awareness of the disease and meticulous analysis of preoperative heart imaging are important to avoid an unnecessary surgery.

Risk of Out-of-Hospital Cardiac Arrest in Aged Individuals in Relation to Cold Ambient Temperature　- A Report From North Tochigi Experience.

BACKGROUND: The impact of cold ambient temperature on out-of-hospital cardiac arrest (OHCA) in aged individuals caused by cardiovascular events in indoor environments has not been investigated sufficiently.Methods and Results:We conducted a case-crossover study. The relationship between OHCA caused by cardiovascular events and exposure to minimum temperature <0℃ was analyzed. Conditional logistic regression analysis was performed to estimate the odds ratios for the relationship between exposure to minimum temperature <0℃ and the risk of OHCA. Between January 1, 2011, and December 31, 2015, a total of 1,452 cases of OHCA were documented, and patients were screened for enrollment. A total of 458 individuals were enrolled in this analysis, and were divided into 2 groups of 110 (elderly group: 65-74 years old) and 348 (aged group: ≥75 years old). The aged individuals had a significant increased risk of OHCA after exposure to minimum temperature <0℃ (odds ratio [OR]: 1.528, 95% confidence interval [CI] 1.009-2.315, P=0.045). Cold ambient temperature was an especially significant increased risk for OHCA occurrence for males (OR: 1.997, 95% CI 1.036-3.773, P=0.039) and during winter (OR: 2.391, 95% CI 1.312-4.360, P=0.004) in the aged group. CONCLUSIONS: Cold ambient temperature significantly affected aged individuals (≥75 years old) experiencing an OHCA caused by cardiovascular events in indoor environments.

[Redo Aortic and Mitral Valve Replacement by Manouguian's Procedure for Active Prosthetic Valve Infection].

The damage to the intervalvular fibrous trigone (IVFT) by infective endocarditis makes combined aortic and mitral valve replacement difficult. We performed Manouguian's double valve replacement for such a case and obtained a good result. A 81-year-old male underwent emergency operation due to active prosthetic valve endocarditis. He had a history of receiving combined aortic and mitral valve replacement because of active infective endocarditis at the age of 74 and redo aortic valve replacement 3 years after that. The infectious lesion extended from the mitral annulus to the IVFT and the aortic annulus, and it caused the prosthetic valve detachment from the aortic annulus. Manouguian's double valve replacement was required for radical resection and reconstruction of the IVFT. No recurrent infection or paravalvular leakage was observed during 49months follow up period. Manouguian's procedure is useful for complete resection of the infected IVFT and makes combined aortic and mitral valve replacement safer.

[Second use of preserved aortic cusps for bentall procedure after aortic valve replacement with intravalvular implantation technique in aortitis syndrome].

A 44-year-old woman who had undergone aortic valve replacement with intravalvular implantation technique due to aortitis syndrome 13 years before, required Bentall procedure and hemiarch replacement because of the tissue valve dysfunction and the root and ascending aortic aneurysms. The exposed native aortic cusps sandwiched between the felt pledgets and the tissue valve seemed to be useful in reinforcing the proximal anastomosis of the composite graft. A combination of an intravalvular implantation technique and a skirted composite graft technique was applied, and her postoperative course has been uneventful for more than 2 and a half years.

Macrophage-derived angiopoietin-like protein 2 accelerates development of abdominal aortic aneurysm.

OBJECTIVE: Recently, we reported that angiopoietin-like protein 2 (Angptl2) functions in various chronic inflammatory diseases. In the present study, we asked whether Angptl2 and its associated chronic inflammation contribute to abdominal aortic aneurysm (AAA). METHODS AND RESULTS: Immunohistochemistry revealed that Angptl2 is abundantly expressed in infiltrating macrophages within the vessel wall of patients with AAA and in a CaCl(2)-induced AAA mouse model. When Angptl2-deficient mice were used in the mouse model, they showed decreased AAA development compared with wild-type mice, as evidenced by reduction in aneurysmal size, less severe destruction of vessel structure, and lower expression of proinflammatory cytokines and matrix metalloproteinase-9. However, no difference in the number of infiltrating macrophages within the aortic aneurysmal vessel wall was observed between genotypes. AAA development was also significantly suppressed in wild-type mice that underwent Angptl2-deficient bone marrow transplantation. Expression levels of proinflammatory cytokines and metalloproteinase-9 in Angptl2-deficient macrophages were significantly decreased, and those decreases were rescued by treatment of Angptl2 deficient macrophages with exogenous Angptl2. CONCLUSIONS: Macrophage-derived Angptl2 contributes to AAA development by inducing inflammation and degradation of extracellular matrix in the vessel wall, suggesting that targeting the Angptl2-induced inflammatory axis in macrophages could represent a new strategy for AAA therapy.

Intravascular papillary endothelial hyperplasia in an aneurysm of the superficial temporal artery: Report of a case.

We herein report a rare case of an intravascular papillary endothelial hyperplasia in an aneurysm of the superficial temporal artery. The patient was a 67-year old Japanese woman. She noticed a throbbing swelling in her left forehead, which had gradually been increasing in size. She had no previous history of head trauma. Ultrasonography and three-dimensional computed tomographic angiography revealed an aneurysm with a mural thrombus measuring 10 mm in diameter fed by the frontal branch of the left superficial temporal artery. The aneurysm of the superficial temporal artery was dissected from the surrounding tissues, and was resected after ligation of feeding vessels. A microscopic examination revealed papillary endothelial hyperplasia in a true aneurysm. Nontraumatic aneurysms of the superficial temporal artery are rare. In the previous English literature, there have only been a few reports of papillary endothelial hyperplasia in an artery, and none in an aneurysm of the superficial temporal artery.

Monocyte chemotactic S19 ribosomal protein dimer in atherosclerotic vascular lesion.

To elucidate the molecular mechanism inducing monocyte/macrophage infiltration in the atherosclerotic lesion, we measured the monocyte chemotactic capacity in the extracts of aortic lesions. Five out of seven extracts exhibited significant chemotactic activities. Immunohistochemical examination with an anti-CD68 monoclonal antibody demonstrated that the five positive lesions possessed obvious monocyte/macrophage infiltrations at the intima, whereas the two negative lesions did so at significantly lower intensities. We subjected the chemotactic extracts to immunological analyses to identify the monocyte chemoattractant in them. The monocyte chemotactic capacities of all positive extracts were removed with anti-S19 ribosomal protein (RP S19) antibody beads and antimonocyte chemoattractant protein-1 (MCP-1) antibody beads. In three of the five extracts, the anti-RP S19 antibody beads were more effective than the anti-MCP-1 antibody beads for removal, while in the remaining two extracts, the opposite was observed. A combined immunoabsorption with these beads depleted the monocyte chemotactic capacity of a representative sample of each group. Consistently, the chemotactic capacity of an apparently RP S19 dimer-predominant extract was strongly inhibited by the presence of a C5a receptor antagonist. These results suggest that the RP S19 dimer and MCP-1 play a major role in the monocyte/macrophage infiltration of the atherosclerotic vascular lesion.

Predictive factors for platelet number after cardiopulmonary bypass and postoperative blood loss.

We retrospectively searched for factors that can predict the circulating platelet count after cardiopulmonary bypass (CPB) and postoperative blood loss. Correlations between the circulating platelet count after CPB and several other perioperative variables were investigated in 42 patients who underwent cardiac surgery using the same type of oxygenator. Correlations between perioperative variables and 24 hour postoperative blood loss were also investigated. A multiple stepwise regression analysis showed that the preoperative platelet count, age, and intraoperative blood transfusion values were independent predictors of the circulating platelet count after CPB (R2 = 0.661, p < 0.0001). Gender, operation type, and priority (elective or urgent) were not associated with the platelet count after CPB or postoperative blood loss. Independent predictive factors for postoperative blood loss consisted of age and intraoperative blood loss (R2 = 0.231, p = 0.006). In addition to preoperative platelet count, age and amount of intraoperative blood transfusion are predictive factors for circulating platelet count after CPB. The association of postoperative blood loss with age and intraoperative blood loss may suggest friability of the tissues, including blood vessels, in elderly patients.

[Left ventricular rupture following mitral valve replacement].

Left ventricular rupture following mitral valve replacement is an unusual but highly lethal complication. Between 1982 and 2004, 254 patients underwent mitral valve replacement with coronary artery bypass grafting (CABG) [7 patients], aortic or tricuspid valve operation or both (84 patients), or without concomitant operation (163 patients). There were 11 hospital deaths (4.3%) and 4 left ventricular ruptures (1.6%). No concomitant operation had been performed in all rupture cases. Type I rupture occurred in 2 patients with complete resection of the mitral valve, and type III in the others with preservation of the posterior leaflet or basal chordae. Three of 4 were early and 1 was delayed rupture. The cause of rupture was obvious in 2 patients, over-excision of the posterior mitral annulus (type I) and impingement of the strut (type III). Intra-cardiac, extra-cardiac or both combined surgical repair was attempted under the cardioplegic arrest for all patients, however, 2 of 4 patients died for postoperative low cardiac output syndrome (LOS) and intra-operative bleeding. Techniques of repair and prevention of rupture are discussed.

Successful therapy of brachiocephalic arteriogastric fistula after esophagectomy.

We report the case of an 86-year-old man, who had undergone subtotal esophagectomy and reconstruction with a gastric tube through the retrosternal route 7 years ago, who was referred for treatment of a brachiocephalic arteriogastric fistula. An emergency stent-graft placement was performed to prevent massive bleeding from the fistula. After 2 weeks, a follow-up esophagogastroscopy revealed that the gastric tube ulcer had been penetrated, and the stent graft was exposed. Therefore, surgical treatment was indicated. After a carotid-carotid arterial bypass graft was made, the brachiocephalic artery was resected with the stent graft and the gastric wall. The defect between the cervical esophagus and the remnant gastric tube was replaced by a free jejunal graft. The patient tolerated these procedures well and was transferred to the referral hospital 3 months after surgery. Therefore, both an early diagnosis and the administration of multidisciplinary treatment are essential to save patients presenting with an arterioenteric fistula.

The value of angiogenic therapy with intramyocardial administration of basic fibroblast growth factor to treat severe coronary artery disease.

BACKGROUND: Basic fibroblast growth factor (bFGF) was administered intramyocardially together with CABG to induce myocardial neovascularizaton and collateral growth in patients with ungraftable coronary arteries. Coronary angiographic and myocardial scintigraphic findings revealed that the effects of CABG were potentially confounding. METHODS AND RESULTS: Patients in the bFGF group (n = 16) underwent angiogenic therapy using bFGF for ungraftable territory, and incomplete revascularization (IR) patients (n = 22) underwent only CABG. The magnitude of collateral development was assessed by the Rentrop score and collateral connection (CC) grade. Rentrop scores tended to increase among patients in the bFGF group (before vs. after surgery, 1.9 ± 1.2 vs. 2.3 ± 1.2, p = 0.05), but not in the IR group. The CC grade significantly increased among patients in the bFGF group (before vs. after surgery, 1.0 ± 0.9 vs. 1.4 ± 0.5, p <0.05), but not in the IR group. Myocardial perfusion in territories injected with bFGF improved in 13 patients (81%) of the bFGF group, and also in the nonbypassed territory in 4 IR patients (25%) (p <0.05). CONCLUSION: Angiogenic therapy with bFGF induced collateral development and improved myocardial perfusion in territories injected with bFGF.

Effects of intramyocardial administration of slow-release basic fibroblast growth factor on angiogenesis and ventricular remodeling in a rat infarct model.

BACKGROUND: Basic fibroblast growth factor (bFGF) stimulates neoangiogenesis. Incorporation into biodegradable gelatin hydrogels provides the sustained release of bFGF. The effects of intramyocardial injections of slow-release bFGF on neoangiogenesis in a rat model of infarction were investigated. METHODS AND RESULTS: Myocardial infarction was induced in rats using coronary artery ligation. A total of 124 rats received an intramyocardial injection of 20 microg of bFGF, the same amount of bFGF incorporated into gelatin hydrogel (bFGF + gel), gelatin hydrogel (gel) or saline. Ventricular function was evaluated by echocardiography 2 or 4 weeks later. Morphometric and histological analyses were used to evaluate infarct size, vascular density and myocardial apoptosis. Capillary density in the infarct border zone was higher in the bFGF and bFGF + gel groups than in the saline and gel groups at 4 weeks (p<0.001). Arteriolar density was higher in the bFGF + gel group than in the other 3 groups (p<0.05). The bFGF and bFGF + gel groups contained fewer apoptotic cardiomyocytes in the border zone than the saline and gel groups (p<0.01). The bFGF+gel group had thicker (p<0.05) and less expanded infarcts (p<0.01) compared with the saline group at 4 weeks. CONCLUSIONS: Incorporation of bFGF in gelatin hydrogels enhanced the effects of bFGF on arteriogenesis, ventricular remodeling and cardiac function.

Coronary artery bypass grafting using a bifurcating radial artery.

A 61-year-old man with angina pectoris was admitted for elective coronary artery bypass grafting. The left anterior descending artery, and the two posterolateral branches (PLA1 and PLA2) of the circumflex artery required bypass grafting. At operation, the distal portion of the left radial artery was found to bifurcate, both branches having an equal size. We decided to use the bifurcating radial artery as a conduit for bypass grafting to the branches of the left circumflex artery. One distal end of the radial artery was subsequently anastomosed to the PLA1 branch and the other distal end was anastomosed to PLA2. Postoperative coronary angiography showed both branches of the radial artery to have good patency.