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Non-bacterial thrombotic endocarditis (NBTE) is a condition that results in the development of vegetation on cardiac valves that are devoid of inflammation and bacteria. We herein report a 60-year-old man who transferred to our hospital because of a systemic embolism and heart failure. A mass in the right atrium and vegetation on the mitral valve were observed. He was first diagnosed with infectious endocarditis according to the Duke criteria. During treatment, however, the patient was diagnosed with antiphospholipid syndrome and cancer. After 4 weeks of antibacterial therapy, the patient underwent open chest surgery, and the postoperative histological diagnosis was NBTE.

Background: Tetralogy of Fallot is a congenital heart disease mostly diagnosed and treated in early childhood. However, there are some adult cases receiving treatment., Case Presentation: We describe a 78-year-old Japanese woman who presented with severely hypertrophic right ventricle, ventricular septum defect, overriding aorta, and severe infundibular stenosis in the right ventricular outflow tract. As hypoxemia was mild and daily exertion was sufficiently possible, home oxygen therapy was introduced. After 1 month, she was referred because of a positive blood culture. The blood culture test was positive four times, therefore, the antibacterial drug was administered according to active infective endocarditis. SpO 2 repeatedly decreased during hospitalization, thus oxygen was needed. As there were infective endocarditis onset and progressive hypoxemia, we planned a surgical correction., Conclusion: Tetralogy of Fallot was diagnosed and successfully treated with complete surgical correction, and the development of infective endocarditis was the definitive indication for surgery at this late age., (© 2024. The Author(s).)

Tetralogy of Fallot was repaired previously in a preschooler through right ventriculotomy, providing excellent exposure for ventricular septal defect closure and right ventricular outflow tract obstruction relief. Herein, we describe the preschooler as a 50-year-old man with untreated atrial septal defect found at pulmonary valve replacement in the remote period after tetralogy of Fallot repair. It was inferred intraoperatively that the previous tetralogy of Fallot was repaired only through right ventriculotomy, and atrial septal defect closure was performed together with pulmonary valve replacement., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Epidemiological data on ruptured aortic aneurysms from large-scale studies are scarce. The aims of this study were to: clarify the clinical course of ruptured aortic aneurysms; identify aneurysm site-specific therapies and outcomes; and determine the clinical course of patients receiving conservative therapy.Methods and Results: Using the Tokyo Acute Aortic Super Network database, we retrospectively analyzed 544 patients (mean [±SD] age 78±10 years; 70% male) with ruptured non-dissecting aortic aneurysms (AAs) after excluding those with impending rupture. Patient characteristics, status on admission, therapeutic strategy, and outcomes were evaluated. Shock or pulselessness on admission were observed in 45% of all patients. Conservative therapy, endovascular therapy (EVT), and open surgery (OS) accounted for 32%, 23%, and 42% of cases, respectively, with corresponding mortality rates of 93%, 30%, and 29%. The overall in-hospital mortality rate was 50%. The prevalence of pulselessness was highest (48%) in the ruptured ascending AA group, and in-hospital mortality was the highest (70%) in the ruptured thoracoabdominal AA group. Multivariable logistic regression analysis indicated in-hospital mortality was positively associated with pulselessness (odds ratio [OR] 10.12; 95% confidence interval [CI] 4.09-25.07), and negatively associated with invasive therapy (EVT and OS; OR 0.11; 95% CI 0.06-0.20)., Conclusions: The outcomes of ruptured AAs remain poor; emergency invasive therapy is essential to save lives, although it remains challenging to reduce the risk of death.

This study aimed to evaluate the anatomical reproducibility of a preoperative intracardiac 3D image (IC image) created using computed tomography, and to investigate its usefulness as a surgical decision-making tool. Between 2012 and 2022, ventricular septal defect (VSD) patients, and double outlet right ventricle (DORV) or transposition of the great arteries (TGA) with pulmonary stenosis (PS) patients who underwent cardiac surgery and had preoperative computed tomography were enrolled. SYNAPSE VINCENT® (Fujifilm) was used to create an IC image which was analyzed retrospectively. In 14 VSD patients, the diagnostic consistency rate in the Soto classification with intraoperative findings was 100% (14/14) for IC image versus 64% (9/14) for transthoracic echocardiography (P = 0.04). The defect size showed a higher correlation coefficient with IC image (0.837, P = 0.001) than with transthoracic echocardiography (0.567, P = 0.034). In 11 DORV/TGA with PS patients, the diagnostic consistency rate in the Lev classification was 100% (9/9) for IC image versus 77% (7/9) for transthoracic echocardiography (P = 0.47). The secondary interventricular foramen (SVF)/left ventricular outflow tract (LVOT) ratio by IC image was significantly smaller in the biventricular-repair group (median 0.71, IQR 0.67-1.06) than in the univentricular-repair group (median 1.79, IQR 1.53-2.42) (P = 0.006). An IC image is useful as a surgical decision-making tool for simple VSDs and complex congenital heart diseases such as DORV or TGA with pulmonary stenosis. The SVF/LVOT ratio determined from the IC image may be a useful indicator for avoiding LVOT obstruction., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Sex differences in the clinical presentation and outcomes of DeBakey type I/II (Stanford type A) acute aortic dissection (AAD) remain unclear., Objectives: The authors aimed to determine the impact of sex on the clinical presentation and in-hospital outcomes of surgically or medically treated patients with type I/II AAD., Methods: We studied 3,089 patients with type I/II AAD enrolled in multicenter Japanese registry between 2013 and 2018. The patients were divided into 2 treatment groups: surgical and medical. Multivariable logistic regression was used to examine the association between sex and in-hospital mortality., Results: In the entire cohort, women were older and more likely to have hyperlipidemia, previous stroke, altered consciousness, and shock/hypotension at presentation than men. Women had higher proportions of intramural hematomas and type II dissections than men. In the surgical group (n = 2,543), men had higher rates of preoperative end-organ malperfusion ( P  = 0.003) and in-hospital mortality ( P  = 0.002) than women. Multivariable analysis revealed that male sex was associated with higher in-hospital mortality after surgery (OR: 1.71; 95% CI: 1.24-2.35; P  < 0.001). In the medical group (n = 546), women were older and had higher rates of cardiac tamponade ( P  = 0.004) and in-hospital mortality ( P  = 0.039) than men; no significant association between sex and in-hospital mortality was found after multivariable adjustment (OR: 0.95; 95% CI: 0.56-1.59; P  = 0.832)., Conclusions: Male sex was associated with higher in-hospital mortality for type I/II AAD in the surgical group but not in the medical group. Further research is needed to understand the mechanisms responsible for worse surgical outcomes in men., Competing Interests: Data collection and maintenance for the Tokyo CCU Network registry is financially supported by the 10.13039/100019702Tokyo Metropolitan Government, which played no role in the execution of this study or the interpretation of the results. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2023 The Authors.)

Objectives: Preventing loss of life in patients with type A acute aortic dissection (AAD) who present with cardiopulmonary arrest (CPA) can be extremely difficult. Thus, we investigated the early outcomes in these patients., Methods: Patients with type A AAD who were transported to hospitals belonging to the Tokyo Acute Aortic Super-network between January 2015 and December 2019 were considered for this study. We assessed the early mortality of these patients presenting with CPA and also investigated the differences in outcomes between patients with out-of-hospital and in-hospital CPA., Results: A total of 3307 patients with type A AAD were transported, 434 (13.1%) of whom presented with CPA. The overall mortality of patients presenting with CPA was 88.2% (383/434), of which 94.5% (240/254) experienced out-of-hospital CPA and 79.4% (143/180) experienced in-hospital CPA (P < 0.001). Multivariable analysis revealed that aortic surgery [odds ratio (OR), 0.022; 95% confidence interval (CI), 0.008-0.060; P < 0.001] and patient age over 80 years (OR, 2.946; 95% CI, 1.012-8.572; P = 0.047) were related with mortality in patients with type A AAD and CPA. Between in-hospital and out-of-hospital CPA, the proportions of DeBakey type 1 (OR, 2.32; 95% CI, 1.065-5.054; P = 0.034), cerebral malperfusion (OR, 0.188; 95% CI, 0.056-0.629; P = 0.007), aortic surgery (OR, 0.111; 95% CI, 0.045-0.271; P = 0.001), age (OR, 0.969; 95% CI, 0.940-0.998; P = 0.039) and the time from symptom onset to hospital admission (OR, 1.122; 95% CI, 1.025-1.228; P = 0.012) were significantly different., Conclusions: Patients with type A AAD presenting with CPA exhibited extremely high rates of death. Patient outcomes following in-hospital CPA tended to be better than those following out-of-hospital CPA; however, this difference was not significantly different. To prevent deaths, aortic surgery, when possible, should be considered in patients with type A AAD who sustained CPA., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Various postoperative predictive markers following cardiovascular surgery have been examined for use in the current aging population. The controlling nutritional status (CONUT) score, which is advocated not only as a screening tool for poor nutritional status, but also as an immunonutritional assessment, has started to attract attention in several clinical settings, such as in cancer and heart failure patients. The aim of this study was to evaluate the value of the CONUT score as a postoperative prognostic marker in patients who underwent cardiovascular surgery., Methods: A total of 75 patients who underwent elective cardiovascular surgery between January 2015 and October 2017 were retrospectively analyzed. The patients were divided into two groups according to their preoperative CONUT score (i.e., CONUT < 2 or CONUT ≥ 2), and their clinicopathological characteristics, surgical outcomes, and overall survival were compared. The median follow-up period was 23 months (range 0-43 months) after surgery., Results: The high CONUT group (CONUT ≥ 2), which consisted of 30 (40.0%) patients, had a significantly worse prognosis than the low CONUT group with regard to overall survival (p = 0.0007). On multivariate analyses, the CONUT score was identified as the only independent prognostic factor for overall survival (hazard ratio 1.47 per 1 CONUT score increase, 95% confidence interval 1.05-2.06, p < 0.026)., Conclusions: The CONUT score is a reliable and independent preoperative predictor of overall survival after cardiovascular surgery.

A 5-year-old girl has a history of epicardial VVI-pacemaker implantation due to congenital heart block at the age of 2 months. Five years later, she developed heart failure at the same time of battery depletion. The chest X-ray indicated the loop formation of the epicardial leads and the echocardiogram demonstrated paradoxical movement of ventricles. The 3-dimensional computed tomography finally revealed strangulation of biventricular apex caused by loop of the leads. She underwent reoperation. Cardiac strangulation was relieved by total removal of the loop and repositioning of right atrial and ventricular electrodes in a gentle curve of the leads. She was discharged and doing well. Cardiac strangulation is a rare, but it can be lethal. Therefore epicardial pacemaker leads should not be positioned around the ventricle with excessive redundancy.

Background: Postoperative fluid management is important after open heart surgery, because cardiopulmonary bypass evokes an abnormal inflammatory response and increases vascular permeability, especially in pediatric patients. We assessed the safety and effectiveness of tolvaptan for management of postoperative fluid retention after congenital heart surgery., Methods and Results: This retrospective study analyzed data from 43 children with uncomplicated congenital heart disease who underwent open heart surgery between September 2013 and August 2016. The patients were divided into two groups. Group N (n = 18; September 2013 through May 2014) received the conventional oral diuretics alone, and Group T (n = 25; June 2014 through August 2016) received a single dose of tolvaptan (0.45 mg/kg) in addition to the conventional oral diuretic therapy. Data were collected, while patients who received intensive care were assessed and compared between groups. Add-on tolvaptan use was associated with increased urinary output standardized by body weight (54.3 ± 4.5 vs 47.3 ± 19.1 mL/kg; p = 0.043), decreased additional intravenous diuretic dose standardized by body weight (0.26 ± 0.23 vs 0.62 ± 0.48 mg/kg; p = 0.001), and a smaller decrease in central venous pressure (1.3 ± 2.7 vs 1.9 ± 3.8 mmHg; p = 0.019). Laboratory analysis showed that electrolyte concentrations in blood and urine did not significantly differ between groups., Conclusions: Tolvaptan appears to be effective and safe for management of postoperative fluid retention after congenital heart surgery.

A 52-year-old male patient with a history of total arch replacement using the elephant trunk technique for acute aortic dissection 4 years before visited our hospital with the chief complaint of persistent fever. Chest computed tomography (CT) suggested prosthetic vascular graft infection, which was treated surgically after chemotherapy. The first surgery consisted of debridement of an abscess around the vascular graft and in the aorta around the elephant trunk, and thoracic descending aorta replacement and vacuum-assisted closure (VAC) in view of the risk of bleeding from the peripheral region of the elephant trunk. One week later, omental filling was performed as the second step. This is a very rare case of aortic abscess around the elephant trunk that could successfully be managed by graft-conserving treatment.

Purpose: We examined grafts employing for morphological analysis of early and long-term results on proximal anastomosis with the PAS-Port(®)., Methods: One hundred and four patients treated by OPCAB with PAS-Port(®) were performed postoperative MDCT. Morphological evaluation of the proximal anastomotic region was classified into three groups (A; graft was anastomosed almost perpendicularly to the aortic wall, B; graft was same type A, but subsequently curved to form an acute angle with the aortic wall, C; graft take off acute angle with the aortic wall) evaluated on planar and sagittal sections., Results: One hundred twenty-six PAS-Port(®) were used. Patency rate was 99.0% at discharge, 94.7% at 1 year, and no blockages were detected thereafter in patients examined. The morphology rate was A 50.6%, B 15.3% and C 34.1% on planar sections, and A 58.8%, B 10.6% and C 30.6% on sagittal sections., Conclusion: The morphological evaluation of grafts revealed the degree of freedom in graft design to be relatively high and long-term patency posed no particular problem even if the layout of the proximal anastomotic region involved a relatively acute angle. The PAS-Port(®) was considered to be a highly reliable device which performed appropriate proximal anastomosis and improved the patency of vein grafting to the aortic wall.

Prosthetic vascular graft infection in the thoracic aortic area is a rare but serious complication. Adequate management of the complication is essential to increase the chance of success of open surgery. While surgical site infection is suggested as the root cause of the complication, it is also related to decreased host tolerance, especially as found in elderly patients. The handling of prosthetic vascular graft infection has been widely discussed to date. This paper mainly provides a summary of literature reports published within the past 5 years to discuss issues related to multidisciplinary treatment approaches, including surgical site infection, timing of onset, diagnostic methods, causative pathogens, auxiliary diagnostic methods, antibiotic treatment, anti-infective structures of vascular prostheses, surgical treatment, treatment strategy against infectious aortic aneurysms, future surgical treatment, postoperative systemic therapy, and antimicrobial stewardship. A thorough understanding of these issues will enable us to prevent prosthetic vascular graft infection in the thoracic aortic area as far as possible. In the event of its occurrence, the early introduction of appropriate treatment is expected to cure the disease without worsening of the underlying pathological condition.

A 49-year-old man was diagnosed with an interrupted aortic arch (IAA), a massive saccular thoracic collateral aneurysm, ischemic renal insufficiency, and multiple abdominal collateral aneurysms. A bypass from the left subclavian artery to the descending aorta and thoracic collateral aneurysmectomy proceeded simultaneously through a posterolateral thoracotomy. The pressure gradient between upper and lower extremities disappeared and renal function was normalized. Thoracic collateral aneurysmectomy and a simultaneous bypass from the left subclavian artery to the descending aorta with postoperative normalization of ischemic renal insufficiency are extremely rare in adult patients with IAA, and the remaining abdominal collateral aneurysms require careful monitoring., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The artery and vein of the transplanted kidney are generally anastomosed to the external iliac artery and vein, respectively. Therefore, in open abdominal artery aneurysm (AAA) repair in renal transplant patients, kidney ischemia due to a proximal aortic clamp is a serious problem. We successfully performed endovascular aneurysm repair (EVAR) of AAA without aortic clamping in two renal transplant recipient cases. The two patients were diagnosed with large AAAs following the renal transplant, and EVAR was performed. To protect the renal function, we used N-acetylcysteine premedication and hydration before the operation, and we could then reduce the iodine contrast medium by using echography of the artery during the operation. In this report, a case where EVAR with renal function protection is a useful treatment for renal transplant recipients with AAA is described.

Subjects: Currently, hemostatic materials made from human blood components and animal-derived collagen is used for controlling operative hemorrhage in the cardiovascular surgery field. In this study, we focused on an entirely synthetic self-assembling peptide (development code: TDM-621) that gels when in contact with blood or other bodily fluids and stops bleeding upon contact with a wound site. We investigated its usefulness as a hemostatic material in animal and clinical studies., Methods: Before we began the clinical study, we demonstrated the hemostasis efficacy and safety of TDM-621 in animal experimental models. Twenty-five patients (22 men, 3 women) were enrolled in the clinical study, and the following procedures were performed: 1) coronary artery bypass graft (CABG) (n = 9), 2) abdominal aortic graft replacement (n = 4), and 3) peripheral artery bypass (n = 12). The TDM-621 material was applied to a total of 33 vascular anastomotic graft sites (some patients received material at more than one site). Both hemostatic efficacy and safety were examined., Results: A total of 33 anastomotic graft sites in 25 patients were evaluated, and the averaged primary and secondary efficacy rate was 94.5%. No postoperative bleeding or adverse events (including serious adverse events) with a causal relationship to treatment were observed., Conclusion: This study indicated that TDM-621 is a more effective and reliable hemostat than commonly-used general hemostatic agents and, therefore, will be very useful in several cardiovascular surgery applications.

A 38-year-old woman underwent atriopulmonary Fontan surgery at age 18 years and subsequently successfully delivered a girl by cesarean section at age 34. Her condition later deteriorated due to atrial tachyarrhythmia and progressed to New York Heart Association (NYHA) class IV heart failure. Her treatment, at age 36, comprised total cavopulmonary connection conversion, direct right atrial ablation with bipolar radiofrequency devices, the creation of an atrial septal defect, and placement of a dual-chamber permanent pacemaker. Three years after the conversion, her condition has improved to NYHA class I.

A 73-year-old male patient was found to have an abdominal aortic aneurysm complicated with bilateral common iliac artery aneurysms. He also had hepatitis C, chronic liver cirrhosis (Child-Pugh class B), a rupture of esophageal varices, hepatocellular carcinoma, and intractable ascites. The functions of other systemic organs were also impaired. We first performed a right internal iliac artery coil embolization prior to stent graft implantation combined with a left external-internal iliac artery bypass. These additional procedures allowed for safe treatment with stent graft implantation, without any serious complications.

A 74-year-old female patient with left main trunk (LMT) and triple vessel disease underwent coronary artery bypass graft (CABG) surgery. The patient began to experience exertional dyspnea. A coronary artery angiogram confirmed a severe stenosis in the proximal side of the saphenous vein graft (SVG). The patient had impending infarction immediately after the unsuccessful attempt for percutaneous coronary intervention, which resulted in an emergent CABG procedure. A left thoracotomy at the 4th intercostal space was made with the patient in the right lateral position. We then interrupted the use of intra-aortic balloon pumping (IABP), confirmed on transesophageal echocardiography (TEE) that the balloon was in a position distal to the target anastomosis site, and made a proximal anastomosis using the PAS-Port system (Cardica, Redwood City, CA, USA). After its successful deployment, IABP was repositioned back and resumed. The distal anastomosis was made to the previously bypassed graft. The patient had no postoperative myocardial damage or complications and was discharged on postoperative day 21. A redo CABG for post-CABG acute coronary syndrome patient was thought to be an extreme high risk; however, the operative time could be minimized by using the PAS-Port system, which enabled a safe redo CABG with left thoracotomy.

Aortopulmonary window (APW) is a rare congenital heart defect that requires urgent repair, as it can lead to rapid development of pulmonary hypertension. A 6-day-old boy with a total-defect APW was transferred to our hospital and underwent definitive repair on the 15th day after birth. The ascending aorta and pulmonary trunk were divided to create a larger tissue margin on the aortic side for the next seam. Then, the aortic window was sutured and closed directly, while the large pulmonary defect was reconstructed with a fresh autologous pericardial patch. Although peritoneal dialysis was briefly required for acute renal failure due to low output syndrome, his condition improved and he was discharged 22 days after surgery. Six years later, he remains well, without complications or need for medication.

The patient was a 59-year-old female. Because of massive hemoptysis, she was brought to our emergency center by ambulance. Thoracic computed tomography led to a diagnosis of an infectious thoracic aortic pseudoaneurysm accompanied by an aortobronchopulmonary fistula. Emergency surgery followed. Also noted was an advanced hepatic dysfunction, assessed as Child-Pugh score B, caused by an alcoholic liver disease. A localized affected area made it possible for us to perform an aneurysmectomy using a temporary bypass rather than assisted circulation. A patch plasty using expanded polytetrafluoroethylene completed the procedure. Streptococcus agalactiae (GBS) was detected in a sample obtained during the surgery from an abscess located in the aneurysm. The patient made satisfactory postoperative progress and left the hospital walking unaided on the 36th postoperative day.

The occurrence of mediastinitis following synthetic vascular replacement surgery is still associated with an unfavorable prognosis in the treatment of thoracic aortic diseases. This time we report a Bentall procedure that we re-performed to treat an aortic root pseudoaneurysm, which developed after a postoperative mediastinitis. This followed the first Bentall procedure, which was treated by debridement of the focus of infection, continuous lavage, and a two-step rectus abdominis muscle flap implantation. Implantation of a rectus abdominis muscle flap is effective in controlling infection in the treatment of mediastinitis after heart surgery. However, after synthetic vascular replacement surgeries have been performed to treat aortic diseases, especially after aortic root reconstruction surgery, which puts stress on the anastomotic site, consideration should be given regarding the development of hemorrhages and pseudoaneurysms as a result of infection-induced tissue fragilization.

Background: Cell preservation is essential for successful cell transplantation and/or tissue engineering. We examined the effects of cryopreservation on the transplantation of human heart cells., Methods: Cells isolated from human atrial tissues were cultured for 15 days (control group), cryopreserved for 1 week, and rapidly thawed and cultured for 15 days. Proliferation was compared among control and cryopreserved cells or tissues by constructing growth curves. Growth factors, cytokines, biochemical features, and cell cycle phase were measured immediately before and after cryopreservation, and immunogenicity was evaluated from growth curves generated from heart cells after 7 days in mixed-lymphocyte culture. Control or cryopreserved cells were transplanted into rat connective tissues and evaluated histologically 2 weeks later., Results: Cryopreserved cells proliferated more effectively than control cells. Levels of basic fibroblast growth factor and transforming growth factor-β1 were significantly higher, and those of interleukin (IL)-6 and IL-8 were significantly lower after cryopreservation. Fewer peripheral blood lymphocytes were produced in cryopreserved cells than in noncryopreserved cells, and the cell cycle phase of cryopreserved heart cells shifted primarily to G2 + M from G1 + G0. Noncryopreserved and cryopreserved cells both survived in connective tissue., Conclusion: Human atrial cells can be cultured, cryopreserved, and transplanted. Cryopreservation might increase the proliferation of human cells and tissues and also reduce the immunogenicity of heart cells.

Objective: The use of automatic anastomotic devices in coronary artery bypass grafting surgery is associated with lower patency rates in comparison to conventional anastomosis methods. This is thought to be caused by graft curvature occurring after closing of the chest wall., Methods: We evaluated 39 grafts in 28 patients who underwent off-pump coronary artery bypass surgery using the PAS-Port. After surgery, the proximal anastomotic angle of each stent, graft morphology, and patency were evaluated with axial and sagittal views., Results: The angle for the left anterior descending coronary artery segment was relatively obtuse on the left side of the ascending aorta, and the graft loop formation was not necessary. The angle for the left circumflex coronary artery segment was significantly acute for anastomosis from the upper left side of the ascending aorta. Because grafts are under the constraints of a large loop, graft length tended to become easily excessive or deficient. The angle for the right coronary artery segment was relatively obtuse. The space on the right side of the heart was so narrow that in some cases we had difficulty setting out the appropriate graft location to prevent graft curvature. No bending or stenosis was present in any graft, showing a patency rate of 100%., Conclusion: The short-term results of coronary bypass grafting using PAS-Port are satisfactory.

Objectives: Conventional biomaterials are not viable, do not grow, and do not provide contractile effects in cardiac tissue. Foreign synthetic material may become thrombogenic or infected. The most recent cardiac constructs consist of biodegradable material which has the potential to solve these problems. However, dynamic three-dimensional cell culture is necessary because conventional culture is limited to construct tough biografts., Methods: Vascular smooth muscle cells derived from rat aorta were seeded to poly-L-lactide-epsilon-capro-lactone copolymer in three groups; static culture group (static cell seeding + static cell culture), dynamic culture group (dynamic cell seeding + dynamic cell culture), and pre-seeding group [static cell seeding and culture for 1 week (pre-seeding) + dynamic cell culture]. The dynamic cell culture system used an original spinner flask. The pre-seeding technique used static cell seeding and culture before dynamic culture. The three groups were evaluated by cell proliferation and histologic studies., Results: Vascular smooth muscle cells could be proliferated in/on the biodegradable materials. The pre-seeding group cells grew much more efficiently than the other groups. Very few cells were found in the biodegradable materials with the dynamic groups. However, there were many cells in the materials with the static culture group and pre-seeding group, especially the pre-seeding group., Conclusions: Dynamic culture is useful for constructing tough biografts by the pre-seeding technique.

Objective: We investigated the usefulness of perioperative blood glucose control in patients undergoing coronary artery bypass grafting (CABG)., Methods: DM patients were aggressively treated with intensive insulin therapy to achieve a preoperative fasting blood glucose level of 140 mg/dl and a postoperative level of 200 mg/dl. For comparison, patients were divided as follows: (1) DM group vs. non-DM group, and (2) for mean blood glucose level in the intensive care unit (ICU), lower than 200 mg/dl (IL) vs. 200 mg/dl or higher (IH)., Results: (1) In the DM group, the amount of insulin (U) used during surgery was greater (P<0.05), and the duration of ICU stay was longer (P<0.05). The incidence of all complications was higher in the DM group (P<0.05). (2) Between the IH group (54) and the IL group (82), the proportion of DM patients was higher in the IH group (75% vs. 38%, P<0.05). In the IH, the duration of ICU stay (P<0.01) was longer, and the incidence of all complications was higher (P<0.05). (3) In the DM group, the incidence of complications tended to be higher in the IH group. The incidence of complications was extremely low in the non-DM group., Conclusion: Strict perioperative blood glucose control may help to improve the outcomes of CABG.

Objective: We assessed potential limitations of retrograde continuous tepid blood cardioplegia (RCTBC) for myocardial remodeling, represented by hypertrophied and/or dilated myocardium in patients with severe cardiomyopathy following single aortic valve replacement., Methods: The study was conducted on 91 patients who underwent initial single aortic valve replacement with tepid cardiopulmonary bypass (CPB) and RCTBC. Based on the postoperative maximum creatine phosphokinase (max CPK)-MB level, the patients were allocated to Group H (>/=100 IU/mL) with severe cardiomyopathy or Group L (<100 IU/mL) to make intergroup comparisons of preoperative, intraoperative, and postoperative parameter values., Results: Preoperative measurements were as follows: pressure gradient between left ventricle and aorta (DeltaPG), 92.8+/-46.2 mmHg in Group H and 57.9+/-41.6 mmHg in Group L (p<0.01); implanted valve size, 21.0+/-2.2 mm in Group H and 22.8+/-2.2 mm in Group L (p<0.01); left ventricular end-diastolic volume (LVEDV), 155.7+/-73.3 mL in Group H and 224.3+/-101.5 mL in Group L (p<0.01). The rate of RCTBC flow rate increase did not differ between the groups (17.6% in Group H and 20.7% in Group L), while the rate of concomitant use of optional antegrade coronary perfusion was significantly lower in Group H (25%) than in Group L (37%) (p<0.05). Pre- and post-perfusion lactic acid levels in the myocardial protection solution measured every 30 min after aortic cross clamping were higher in Group H than in Group L., Conclusion: The study suggests preoperative high DeltaPG, small aortic root diameter, and low LVEDV, namely, concentrically hypertrophied myocardium, as risk factors for severe cardiomyopathy after RCTBC. RCTBC in patients with any risk factor should be accompanied by an increase in initial continuous perfusion flow and/or aggressive use of intermittent antegrade coronary perfusion.

Objective: To clarify the position of on-pump beating coronary artery bypass (CAB) and to define preoperative indicators of intentional conversion to the procedure in the era of advancement of off-pump CAB (OPCAB), we assessed on-pump beating CAB performed after the introduction of OPCAB., Subjects and Methods: We assessed 130 patients who underwent single CAB [117 (90%) with OPCAB and 13 (10%) with on-pump beating CAB] between August 1999 (when OPCAB was selected as the first-line surgical procedure) and December 2004., Results: No significant differences were seen between the groups in the number of coronary lesions or the prevalence of left main trunk (LMT) lesion. Reduced left cardiac function, cardiac dilatation, and mitral regurgitation (MR) were more remarkable in the on-pump beating CAB group. Preoperative ischemic condition was generally unstable in the both groups. A conversion to on-pump beating CAB occurred at anastomosis for the left anterior descending (LAD) branch in 61% and for the left circumflex (LCX) branch in 15%. LAD patients had more severe left cardiac dysfunction and cardiac dilatation than LCX patients., Conclusion: To perform safe and reliable CAB surgery, cardiovascular surgeons should define preoperative indicators of difficult OPCAB and convert OPCAB to on-pump beating CAB intentionally without hesitation when unstable hemodynamics is detected.

An emergency off-pump coronary artery bypass (OPCAB) was performed successfully in an aged patient with acute coronary syndrome (ACS). The patient, an 80-year-old woman residing in a nursing home, suddenly lost consciousness during lunch. The electrocardiogram (ECG) showed ventricular fibrillation (Vf) but defibrillation successfully recovered the sinus rhythm. The patient was brought to our hospital as an emergency. She underwent emergency cardiac catheterization. Coronary angiography demonstrated severe three vessel disease with left main coronary trunk (LMT) stenosis. Even during intra-aortic balloon pumping (IABP), the hemodynamic state was unstable, with repeated development of ventricular tachycardia and fibrillation. An emergency coronary artery bypass without a cardiopulmonary bypass was performed. Saving her life was of primary importance and revascularization of the left anterior descending artery (LAD) branch, was performed. Thanks to the advances made in various devices, safe and reliable anastomoses have become possible in OPCAB applied to ACS. OPCAB for ACS have become safe and reliable anastomoses following development of various devices. We think that OPCAB is an effective surgical technique for coronary revascularization for emergency or serious cases involving elderly patients.

We evaluated the impact of donor age on the efficacy of myocardial cellular therapy for ischemic cardiomyopathy. Characteristics of smooth muscle cells (SMC), bone marrow stromal cells (MSCs), and skeletal muscle cells (SKMCs) from young, adult, and old rats were compared in vitro. Three weeks after coronary ligation, 3.5 million SMCs (n = 11) or MSCs (n = 9) from old syngenic rats or culture medium (n = 6) were injected into the ischemic region. Five weeks after implantation, cardiac function was assessed by echocardiography and the Langendorff apparatus. In the in vitro study, the numbers and proliferation of MSCs from fresh bone marrow and SKMCs from fresh tissue but not SMCs were markedly diminished in old animals (P < 0.05 both groups). SKMCs from old animals did not reach confluence. After treatment with 5-azacytidine (azacitidine), the myogenic potential of old MSCs was decreased compared with young MSCs. In the in vivo study, both SMC and MSC transplantation induced significant angiogenesis compared with media injections (P < 0.05 both groups). Transplantation of SMCs but not MSCs prevented scar thinning (P = 0.03) and improved ejection fraction and fractional shortening (P < 0.05). Load-independent indices of cardiac function in a Langendorff preparation confirmed improved function in the aged SMC group (P = 0.01) but not in the MSC group compared with the control group. In conclusion, donor age adversely impacts the efficacy of cellular therapy for myocardial regeneration and is cell-type dependent. SMCs from old donors retain their ability to improve cardiac function after implantation into ischemic myocardium.

A 63-year-old man had undergone graft replacement of the descending aorta due to dissection of aortic aneurysm nine years before and closure of an aortobronchopulmonary fistula two years before. He was admitted to our hospital because of massive hemoptysis. Angiography and chest computed tomography (CT) revealed a pseudoaneurysm on the proximal end caused by graft detachment. Intravascular ultrasound clearly revealed half round detachment on both ends of the graft. Replacement of the ascending, arch and distal aorta including the graft was performed, and the patient's postoperative course has been satisfactory. We have concluded that intravascular ultrasound is a useful method for detecting pseudoaneurysm after graft replacement which is not evident on cineangiography, CT or distal subtraction angiography.

Autologous smooth muscle cell (SMC)-seeded biodegradable scaffolds could be a suitable material to repair some pediatric right ventricular outflow tract (RVOT) cardiac anomalies. Adult syngenic Lewis rat SMCs (2 × 106) were seeded onto a new biodegradable copolymer sponge made of ∊-caprolactone-co-L-lactide reinforced with poly-L-lactide fabric (PCLA). Two weeks after seeding, the patch was used to repair a surgically created RVOT defect in an adult rat. At 8 weeks after implantation the spongy copolymer component was biodegraded, and SM tissue and extracellular matrices containing elastin fibers were present in the scaffolds. By 22 weeks more fibroblasts and collagen were present (p < 0.05). The number of capillaries in the grafts also increased (p < 0.001) between 8 and 22 weeks. The fibrous poly-L-lactide component of the PCLA scaffold remained. The 22-week grafts maintained their thickness and surface area in the RVOT. The SMCs prior to implantation were in a synthetic phenotype and developed in vivo into a more contractile phenotype. By 8 weeks the patches were endothelialized on their endocardial surfaces. Future work to increase the SM tissue and elastin content in the patch will be necessary before implantation into a pediatric large-animal model is tested.

Autologous smooth muscle cell (SMC)-seeded biodegradable scaffolds could be a suitable material to repair some pediatric right ventricular outflow tract (RVOT) cardiac anomalies. Adult syngenic Lewis rat SMCs (2 x 10(6)) were seeded onto a new biodegradable copolymer sponge made of epsilon-caprolactone-co-L-lactide reinforced with poly-L-lactide fabric (PCLA). Two weeks after seeding, the patch was used to repair a surgically created RVOT defect in an adult rat. At 8 weeks after implantation the spongy copolymer component was biodegraded, and SM tissue and extracellular matrices containing elastin fibers were present in the scaffolds. By 22 weeks more fibroblasts and collagen were present (p < 0.05). The number of capillaries in the grafts also increased (p < 0.001) between 8 and 22 weeks. The fibrous poly-L-lactide component of the PCLA scaffold remained. The 22-week grafts maintained their thickness and surface area in the RVOT. The SMCs prior to implantation were in a synthetic phenotype and developed in vivo into a more contractile phenotype. By 8 weeks the patches were endothelialized on their endocardial surfaces. Future work to increase the SM tissue and elastin content in the patch will be necessary before implantation into a pediatric large-animal model is tested.

Background: Autologous cell transplantation may restore viable muscle after a myocardial infarction. We compared the effect of three cell types or an angiotensin-converting enzyme (ACE) inhibitor on preservation of ventricular function after cardiac injury., Methods: A uniform transmural myocardial scar was created in adult rats by cryoinjury. Three weeks later the rats were randomly assigned to one of four blinded treatments: transplantation with 5 x 10(6) aortic smooth muscle cells (SMC, n = 12), ventricular heart cells (VHC, n = 13), skeletal muscle cells (SKC, n = 13) or culture medium alone (control, n = 11). The ACE inhibitor group (n = 8) received enalapril (1.0 mg/kg per day), also beginning 3 weeks after cryoinjury. Five and 12 weeks after transplantation, left ventricle (LV) function was assessed in a Langendorff apparatus, and histologic and immunohistological evaluation of the LV scars was performed., Results: At 5 weeks, greater scar elastin content and better LV function was noted with cell transplantation or ACE inhibitor therapy compared with control rats (p < 0.05). Twelve weeks after transplantation, cell-transplanted rats still had greater elastin content and better LV function than control rats, although elastin content and LV function had declined in ACE inhibitor-treated animals to levels below those observed in control rats (p < 0.05)., Conclusions: Transplantation of SMC, VHC, and SKC preserved ventricular function equivalent to the effects of an ACE inhibitor. Muscle cell transplantation, but not ACE inhibitor therapy, continues to be effective later after cryoinjury. No differences were detected between the muscle cells.

Objective: Cell transplantation to prevent congestive heart failure in patients with inherited dilated cardiomyopathy might require the use of noncardiac donor cells unaffected by the genetic defect and cryopreservation to permit cell storage until the time of transplantation. However, the effects of cryopreservation on peripheral muscle cells harvested from a cardiomyopathic recipient and their subsequent ability to restore cardiac structure and function after transplantation are unknown., Methods: Skeletal myoblasts and vascular smooth muscle cells from cardiomyopathic hamsters (delta-sarcoglycan-deficient BIO 53.58 hamster) and age-matched normal donor hamsters were isolated, expanded in culture, and cryopreserved. After reanimation in culture, cell morphology and growth rate were assessed and compared with values seen in noncryopreserved cells. A total of 4 x 10(6) previously cryopreserved skeletal myoblasts (n = 10) and vascular smooth muscle cells (n = 10) harvested from cardiomyopathic donors were then transplanted into the left ventricles of 17-week-old BIO 53.58 hamsters. Hearts injected with culture medium alone (n = 11) served as controls. Heart function was assessed 5 weeks after transplantation on a Langendorff apparatus, and left ventricular geometry was quantified by means of computerized planimetry. Staining with 5-bromo-2'-deoxyuridine identified the injected cells., Results: Vascular smooth muscle cells from cardiomyopathic donors had an abnormal morphology and diminished growth rates in culture compared with vascular smooth muscle cells from normal donors. These markers of injury were exacerbated by cryopreservation. In contrast, vascular smooth muscle cells from normal donors and skeletal myoblasts from either cardiomyopathic or normal donors appeared normal in culture and were unaffected by cryopreservation. Both cryopreserved vascular smooth muscle cells and skeletal myoblasts from cardiomyopathic donors formed a viable muscle-resembling tissue that prevented wall thinning, limited left ventricular dilatation, and preserved global systolic function in hamsters with a genetic dilated cardiomyopathy. However, attenuation of cardiac remodeling and preservation of global heart function was greater after skeletal myoblast transplantation compared with vascular smooth muscle cell transplantation in parallel to the in vitro morphologic and growth characteristics of these cells., Conclusions: Cryostorage of healthy donor cells does not prevent the benefits of cell transplantation on limiting remodeling and preserving cardiac function in the failing heart. The health of donor cells in vitro predicts their subsequent benefits on cardiac structure and function after transplantation. Cryopreservation of donor cells might facilitate a clinically applicable and effective approach for ventricular restoration with cell-transplantation therapy for patients with inherited dilated cardiomyopathy.

Muscle cell transplantation may delay or prevent cardiac dilation in dilated cardiomyopathy. The present study was designed to compare the effects of the heart function of smooth muscle cell (SMCs) auto-transplantation and heart cell (CMs) allo-transplantation in dilated cardiomyopathic hamsters, and to determine which cells are better for cell transplantation. CMs and SMCs were isolated from BIO 53.58 hamsters, and cultured for transplantation. CMs, SMCs (4 X 10(6) cells each) or culture medium were transplanted into 17 weeks old BIO 53.58 hamsters to achieve CM transplantation (CMTx), SMC transplantation (SMCTx), and controls (Con) (N=10 each). Cyclosporine (5 mg/Kg) was administered subcutaneously to CMTx. Healthy hamsters (sham, N=6) were used to compare heart functions. Four weeks after transplantation, heart function was evaluated in all groups using a Langendorff perfusion apparatus. Histology demonstrated severe focal myocardial necrosis in the dilated cardiomyopathic hearts. CMTx and SMCTx formed huge muscle tissue in the dilated myocardium. Sham, SMCTx, and CMTx had a better heart function than Con (p < 0.01), and SMCTx had a better peak systolic pressure (p < 0.05) and developed pressure (p < 0.05) than CMTx at any balloon volume. However, sham and SMCTx were not statistically different. SMCTx and CMTx formed muscle tissue and produced better heart function in the cardiomyopathic hearts, and SMCTx showed better systolic and developed pressures than CMTx, even though they were similar in other functions. Significantly, SMCTx had heart functions, which were similar to those of healthy hamster's hearts.