[Spontaneous Rupture of the Ascending Aorta;Report of a Case].

A 66-year-old woman was transferred to our hospital on an emergency basis complaining of a sudden onset of chest discomfort. An emergency contrasted computed tomography showed a ruptured the ascending aorta near the right pulmonary artery with a hematoma and notch in the aortic wall. An emergency operation of the graft replacement was performed via standard median sternotomy under the cardiac arrest with aortic clamp. Upon the operation, there was a 1.5 cm rupture site in the central portion of the ascending aorta. There was no specific evidence of aortic aneurysm or dissection, therefore a spontaneous rupture of the ascending aorta was diagnosis. The pathological finding was normal without pathological changes of cystic medial necrosis or atheroma. The postoperative course was uneventful and he was discharged 14 days after surgery.

Clinical outcomes of thoracic endovascular aneurysm repair using commercially available fenestrated stent graft (Najuta endograft).

OBJECTIVE: Thoracic endovascular aneurysm repair (TEVAR) for the aortic arch aneurysm is challenging because of its curved anatomic configuration and the presence of the supra-aortic branches. The Najuta fenestrated endograft (Kawasumi Laboratories, Inc, Tokyo, Japan) was developed to treat aortic arch diseases, offering maximal proximal landing length while preserving the blood flow to the supra-aortic branches. We evaluated the perioperative and midterm outcomes of this fenestrated endograft. METHODS: Between July 2007 and July 2013, 32 patients were treated with the Najuta endograft at three vascular centers. The mean age of the patients was 74.5 ± 9.8 years (23 patients were men). Technical success, complication, overall survival rate, freedom from aneurysm-related death, secondary intervention, aneurysm enlargement, device migration, and patency of supra-aortic branches were investigated retrospectively. RESULTS: The median follow-up period was 2.5 years (range, 0.2-6.2 years). Seventy-one supra-aortic vessels (30 brachiocephalic arteries, 31 left common carotid arteries, 10 left subclavian arteries) were planned to be preserved with fenestrations. Technical success rate was 91% (29 of 32; three type I endoleaks were seen), and five perioperative complications (two Stanford A dissections, one cerebral infarction, one celiac artery obstruction, one spinal cord ischemia) were recognized. Perioperative death was not observed. Overall survival rate and rate of freedom from aneurysm-related death at 3 years were 67% and 97%, respectively. The rate of freedom from secondary intervention and the rate of freedom from aneurysm enlargement at 3 years were 84% and 85%, respectively. Device migration was not observed. There were two branch (left carotid artery and left subclavian artery) occlusions at 2 weeks after TEVAR due to the endograft's infolding. No other branch occlusion was seen in this follow-up period. As a result, the patency rate of the supra-aortic branch was 97% at 3 years. CONCLUSIONS: The perioperative and 3-year outcomes of TEVAR using the Najuta precurved, fenestrated endograft demonstrated high freedom from aneurysm enlargement and patency rates of the supra-aortic branches.

[Successful endovascular repair of a ruptured thoracoabdominal aortic aneurysm with severe mural thrombus].

A 51-year-old man was transferred to our hospital on an emergency basis complaining of a sudden onset of severe left lumbar back pain. An emergency contrasted computed tomography showed a ruptured thoracoabdominal aortic aneurysm( rTAAA:Crawford classification type III). The ruptured site was near the aortic bifurcation, and the aneurysm had a relatively narrow segment with an extensive mural thrombus just below the renal arteries. Considering the high mortality of open surgery for the rTAAA and the poor general condition of the patient, we decided to perform endovascular aneurysm repair (EVAR) as a rescue procedure using the narrowed segment by the thrombus for a proximal landing zone. The abdominal part of the thoracoabdominal aortic aneurysm (TAAA) was successfully excluded with a stent graft to obtain complete hemostasis. The postoperative course was uneventful except for the need for hemodialysis. Even though there is a risk of developing late type 1 endoleak, this procedure can be a feasible option as a rescue procedure or a bridge to radical open surgery for ruptured TAAA in a specially anatomical setting like this case.

Transmitral resection of a left ventricular apical papillary fibroelastoma using video-assisted thoracoscopy.

Papillary fibroelastomas (PFEs) are rare benign tumors usually found on cardiac valves, and do not commonly originate from the left ventricle (LV). We report a 74-year-old female with a PFE in the LV apex. We performed complete resection of the tumor through a transmitral approach using video-assisted thoracoscopy.

[Hybrid endovascular repair with reconstruction of superior mesenteric and celiac arteries for thoracoabdominal and abdominal aortic aneurysms].

A 79-year-old woman presented with sustained thoracolumbar back pain. Contrasted computed tomography (CT) showed a thoracoabdominal aortic aneurysm (TAAA: type I of Crawford classification) and an abdominal aortic aneurysm (AAA) that were not ruptured. Considering her age, the placement of an endovascular stent graft was performed for TAAA at the possible sacrifice of the celiac (CA) and superior mesenteric arteries (SMA). In order to prevent ischemic events, it was necessary that blood supply to the CA and SMA was maintained by placing a graft to each artery from the Y-shaped graft for replacement of AAA. Actually, only CA was sacrificed and coil embolization of CA was needed because of type 2 endoleak. The patient was discharged 17 days after surgery. A hybrid technique, endovascular repair with reconstruction of abdominal branches for TAAA and AAA, can be an alternative procedure for such high-risk operation with multiple aortic aneurysms including TAAA.

[Simultaneous endovascular aortic aneurysm repair and coronary artery bypass grafting in a patient with abdominal aortic aneurysm and left main trunk lesion].

To patients with severe coronary artery disease (CAD) and expanding large abdominal aortic aneurysm (AAA), simultaneous coronary artery bypass grafting (CABG) and AAA repair has been recommended. A 68-year-old woman had a CAD and an AAA 71 mm in diameter which was enlarging. Coronary angiography showed severe stenoses in the left main trunk (LMT), the left anterior descending artery and the circumflex artery. On-pump beating CABG and AAA repair with endovascular aneurysm repair (EVAR) were performed simultaneously, because intraaortic balloon pumping (IABP) might be needed due to severe stenoses of LMT. Just after EAVR, on-pump beating CABG was performed. The patient was discharged 15 days after the operation. It was suggested that a simultaneous operation of CABG and EVAR might be safe and effective for high risk patients with CAD and AAA.

Repair of a recurrent pseudoaneurysm of the ascending aorta in an atomic bomb survivor with myelodysplastic syndrome.

The occurrence of infective aortic pseudoaneurysms tends to be intractable and difficult to treat. We experienced a very rare case of a recurrent infective pseudoaneurysm in the ascending aorta that occurred after cardiac surgery in an atomic bomb survivor with myelodysplastic syndrome. The pseudoaneurysm was successfully repaired using a femoral artery autograft with an omentopexy and the patient recovered well without any recurrence.

New tubular bioabsorbable knitted airway stent: biocompatibility and mechanical strength.

OBJECTIVE: This study examines the biocompatibility and suitability of a new tubular bioabsorbable knitted stent made of poly-L -lactic acid in normal rabbit airways and examines the mechanical strength of this stent in vitro. METHODS: A tubular knitted airway stent (group B, n = 15) made of poly-L -lactic acid wire was implanted operatively in New Zealand White rabbits intratracheally; silicone stents served as controls (group A, n = 8). The cervical trachea was exposed, and the stent was implanted. Up to 40 weeks after stent implantation, the rabbits were killed, at which time bronchoscopy, histologic examination, and scanning electron microscopic study was done. We tested poly-L -lactic acid stents and silicone stents for their mechanical strength in vitro. We subjected stents to area loads and measured their mechanical strengths. RESULTS: In group A, which received silicone stents, 3 (37.5%) rabbits died within 4 weeks of stent implantation as a result of airway obstruction by secretions inside the stent lumen. In group B, poly-L -lactic acid stents, 1 (6.7%) rabbit died 3 weeks after implantation because of weakness caused by anorexia. In the remaining animals, except for 1 animal with stent trouble, the bronchial lumen was fully open until the 40th week after implantation. After 40 weeks of follow-up, the stents disappeared, except for nonabsorbable suture in the bronchial wall. None of the animals in group B died of airway complication. Histologic examination and scanning electron microscopic examination of the group A silicone stents showed marked regression of ciliated cells under the stent. In group B the ciliated epithelium was preserved, and there were numerous capillary blood vessels in the submucosa. In scanning electron microscopy of the group B poly-L -lactic acid stents, the ciliated cells were preserved between the mesh holes of the stent. For diameters between 4 and 6 mm, the mechanical strength of silicone stents was greater than that of poly-L -lactic acid stents. However, the mechanical strength of poly-L -lactic acid stents increased as a function of their diameter. CONCLUSION: A new tubular bioabsorbable stent made of poly-L -lactic acid is biocompatible in normal rabbit airways, indicating that poly-L -lactic acid is a promising material for airway stents for clinical use.

Successful hybrid treatment for a ruptured thoracoabdominal aortic aneurysm in a patient with systemic lupus erythematosus.

A 49-year-old woman with a 27-year history of systemic lupus erythematosus (SLE) was admitted to our hospital with sudden-onset severe back pain. An emergency multidetector computed tomography (MDCT) revealed a ruptured thoracoabdominal aortic aneurysm (TAAA) 80 mm in diameter. Considering her condition and comorbidities, we performed an emergency hybrid treatment: visceral reconstruction followed by endoluminal aneurysm exclusion. She recovered uneventfully, except for the need for temporary hemodialysis. TAAA complicated with SLE is extremely rare. To our knowledge, this is the first successful report in the English literature of a ruptured TAAA in a patient with SLE who underwent hybrid treatment.

Temporary blockade of contractility during reperfusion elicits a cardioprotective effect of the p38 MAP kinase inhibitor SB-203580.

p38 MAP kinase activation is known to be deleterious not only to mitochondria but also to contractile function. Therefore, p38 MAP kinase inhibition therapy represents a promising approach in preventing reperfusion injury in the heart. However, reversal of p38 MAP kinase-mediated contractile dysfunction may disrupt the fragile sarcolemma of ischemic-reperfused myocytes. We, therefore, hypothesized that the beneficial effect of p38 MAP kinase inhibition during reperfusion can be enhanced when contractility is simultaneously blocked. Isolated and perfused rat hearts were paced at 330 rpm and subjected to 20 min of ischemia followed by reperfusion. p38 MAP kinase was activated after ischemia and early during reperfusion (<30 min). Treatment with the p38 MAP kinase inhibitor SB-203580 (10 microM) for 30 min during reperfusion, but not the c-Jun NH(2)-terminal kinase inhibitor SP-600125 (10 microM), improved contractility but increased creatine kinase release and infarct size. Cotreatment with SB-203580 and the contractile blocker 2,3-butanedione monoxime (BDM, 20 mM) or the ultra-short-acting beta-blocker esmorol (0.15 mM) for the first 30 min during reperfusion significantly reduced creatine kinase release and infarct size. In vitro mitochondrial ATP generation and myocardial ATP content were significantly increased in the heart cotreated with SB-203580 and BDM during reperfusion. Dystrophin was translocated from the sarcolemma during ischemia and reperfusion. SB-203580 increased accumulation of Evans blue dye in myocytes depleted of sarcolemmal dystrophin during reperfusion, whereas cotreatment with BDM facilitated restoration of sarcolemmal dystrophin and mitigated sarcolemmal damage after withdrawal of BDM. These results suggest that treatment with SB-203580 during reperfusion aggravates myocyte necrosis but concomitant blockade of contractile force unmasks cardioprotective effects of SB-203580.

Surgical experience with right atrial-aortic fistula and penetration of the superior vena cava by a protruding Accufix atrial J-shaped retention wire.

A 57-year-old woman who had a dual chamber pacemaker implanted in June 1990 for sick sinus syndrome had developed heart failure since 1993. Although fluoroscopy revealed that the proximal J-shaped retention wire of the lead had fractured and had protruded through the outer insulation in 1994, and also that the distal J-shaped retention wire of the lead had protruded through the outer insulation in 1997, a transthoracic echocardiographic examination diagnosed tricuspid valve regurgitation, suggesting that the right atrial-aortic fistula might have been overlooked. In an attempt to avoid migration of the J-shaped retention wire from the lead and to repair the tricuspid regurgitation, it was decided that an operation be performed; however, intraoperative transesophageal echocardiography showed a right atrial-aortic fistula. Intraoperative inspection also revealed that the right atrial-aortic fistula and penetration of the superior vena cava had been caused by the Accufix atrial J-shaped retention wire. Under total cardiopulmonary bypass and induced cardiac arrest, a right atriotomy was performed and the atrial and ventricular leads were removed from the tips. The atrial orifice of the fistula and the aortic orifice were closed. Finally, a new dual-chamber pacing system with bipolar epicardial pacing leads was implanted. Postoperative inspection revealed that the proximal retention wire had fractured, the tip of the retention wire had protruded through the outer insulation, and the distal J-shaped outer insulation was damaged.