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BackgroundThis study aimed to compare the short-term outcomes of surgical treatment for acute type A aortic dissection between patients undergoing cardiopulmonary arrest at the time of entry into the operating room and patients who received successful preoperative cardiopulmonary resuscitation before entering the operating room or patients who had cardiopulmonary arrest on the operating room table after entering the operating room without cardiopulmonary arrest. In the present study, we focused on the circulatory status at the time of entering the operating room because it is economically and emotionally difficult to cease intervention once the patient has entered the operating room, where surgeons, anesthesiologists, nurses, and perfusionists are already present, all necessary materials are packed off and cardiopulmonary bypass have already been primed.MethodsTwenty (5.5%) of 362 patients who underwent surgical treatment for acute type A aortic dissection between January 2016 and March 2022 had preoperative cardiopulmonary arrest. To compare the early operative outcomes, the patients were divided into the spontaneous circulation group (n = 14, 70.0%) and the non-spontaneous circulation group (n = 6, 30.0%) based on the presence or absence of spontaneous circulation upon entering the operating room. The primary endpoint was postoperative 30-day mortality. The secondary endpoints included in-hospital complications and persistent neurological disorders.ResultsThirty-day mortality was 65% (n = 13/20) in the entire cohort; 50% (n = 7/14) in the spontaneous circulation group and 100% (n = 6/6) in the non-spontaneous circulation group. The major cardiopulmonary arrest causes were aortic rupture and cardiac tamponade (n = 16; 80.0%), followed by coronary malperfusion (n = 4; 20.0%). Seven patients (50.0%) survived in the spontaneous circulation group, and none survived in the non-spontaneous circulation group (P = .044). Five survivors walked unaided and were discharged home; the remaining two were comatose and paraplegic.ConclusionsThe outcomes were extremely poor in patients with acute type A aortic dissection who had preoperative cardiopulmonary arrest and received ongoing cardiopulmonary resuscitation at entry into the operating room. Therefore, surgical treatment might be contraindicated in such patients.

IntroductionAt our institution, we perform off-pump coronary artery bypass (OPCAB) as a standard procedure. Moreover, patients with favorable coronary anatomy and condition are selected for minimally invasive cardiac surgery (MICS)-OPCAB. We retrospectively compared early outcomes, focusing on safety, between MICS-OPCAB and conventional off-pump techniques for multivessel coronary artery bypass grafting (CABG).MethodsFrom August 2017 to September 2022, 1,220 patients underwent multivessel coronary artery grafting at our institution. They were divided into the MICS-OPCAB group (MICS group = 163 patients) and the conventional OPCAB group (MS group = 1057 patients). Propensity score matching (1 : 1 ratio) was applied to the MICS-OPCAB and MS groups (149 patients per group) based on 23 preoperative clinical characteristics.ResultsAfter matching, there were no significant differences in preoperative characteristics between the groups. The MICS group had a lower total graft number (2.3 ± 0.6 vs. 2.9 ± 0.8, p

IntroductionThe procedure called the “aorta no-touch” (NT) or anaortic technique in off-pump coronary artery bypass grafting (OPCAB) is designed to reduce the perioperative risk of stroke. We have observed an increased frequency of anaortic OPCAB procedures at our institution. The main purpose of the present study is to investigate the effectiveness of anaortic OPCAB in reducing the perioperative risk of stroke.MethodsFrom April 2011 to July 2023, a total of 2,236 patients underwent isolated OPCAB at our single center. The patients were divided into the anaortic group (NT, n = 762) and the aortic group (A, n = 1,474). The NT group was propensity score-matched (PSM) with the A group at a 1:1 ratio (NT n = 640; A n = 640), and matching was performed based on 26 covariates with preoperative clinical characteristics.ResultsIn both the unmatched and matched cohorts of the NT and A groups, there were no significant differences observed in new stroke rates (NT vs. A; unmatched, 1.0% vs. 1.2%, p = 0.624; matched, 0.9% vs. 1.3%, p = 0.789). The univariable logistic analysis did not identify the anaortic technique as an independent factor negatively associated with new stroke events (OR = 0.81, 95% CI = 0.35–1.86, p = 0.624).ConclusionThe present study did not find the anaortic technique to reduce the perioperative risk of stroke in OPCAB. Hence, further large studies are needed to identify patient cohorts in which anaortic OPCAB is significantly beneficial.

Abstract We elucidated the efficacy of gut microbiome–altering drugs on pembrolizumab efficacy in patients with metastatic urothelial carcinoma (mUC). Clinical data were analyzed retrospectively from 133 patients with mUC who received second-line pembrolizumab therapy between January 2018 and January 2021, following failed platinum-based chemotherapy. We evaluated the effects of gut microbiome–altering drugs (proton pump inhibitors [PPI]/potassium-competitive acid blockers [P-CAB], H2 blockers, antibiotics, non-steroidal anti-inflammatory drugs [NSAIDs], metformin, antipsychotics, steroids, and opioids), taken by patients within 30 days before/after pembrolizumab treatment, on progression-free survival (PFS) and overall survival (OS). Fifty-one patients received PPI/P-CAB (37/14, respectively); H2 blockers, 7; antibiotics, 35; NSAIDs, 22; antipsychotics, 8; metformin, 3; steroids, 11; and opioids, 29. Kaplan–Meier curves revealed PPI or P-CAB users showed shorter PFS than non-PPI-P-CAB users (p = 0.001, p = 0.005, respectively). Multivariate analysis highlighted PPI/P-CAB use as the only independent prognostic factor for disease progression (hazards ratio: 1.71, 95% confidence interval: 1.14–2.07, p = 0.010) but not death (p = 0.177). Proton pump inhibitors/potassium-competitive acid blockers may decrease the efficacy of pembrolizumab therapy for mUC, possibly via gut microbiome modulation.

Inadvertent renal artery obstruction during endovascular aortic repair is a rare but serious complication. In such cases, endovascular recanalization is typically attempted; however, it can be challenging, leading to many severe cases. Moreover, if treatment is delayed, the blockage time of the renal artery poses a problem. We encountered a case of inadvertent renal artery occlusion during endovascular aortic repair. In this case, bailout stent implantation through a gap between the aortic wall and a stent graft made by a balloon catheter was effective in reducing the renal ischemia time and facilitating the revascularization procedure.

Abstract Background Post-implant right heart failure (RHF) has been recognized as a crucial prognostic factor in patients receiving left ventricular assist devices (LVADs), and its management has long attracted attention from cardiologists and surgeons. Case presentation This report described an 18-year-old female with acutely deteriorating heart failure due to dilated cardiomyopathy who underwent paracorporeal pulsatile-flow LVAD and developed early post-implant RHF. At postoperative day (POD) six, she was almost asymptomatic at rest on 2.5 mg/kg/min of dobutamine; however, the echocardiogram, performed as part of the daily postoperative care, revealed a severely enlarged right ventricle with a decompressed left ventricle, implying the development of post-implant RHF. Bolus infusion of saline and reduction of pump flow (6.0 L/min to 3.0 L/min) led to normalization of both ventricular shapes in 30 s, suggesting that RHF could be managed without surgical interventions. Milrinone was started on POD six, followed by sildenafil administration on POD seven. Fluid balance was strictly adjusted under the close observation of daily echocardiograms. Milrinone and dobutamine were discontinued on PODs 18 and 21, respectively. The patient was listed for a heart transplant on POD 40. Despite reduced right ventricular function (right ventricular stroke work index of 182.34 mmHg*ml/m− 2, body surface area 1.5 m2), she was successfully converted to implantable LVAD on POD 44 with no recurrence of post-implant RHF thereafter for four years. Conclusions In post-implant RHF management, early detection, together with proper and prompt medical management, is crucial to avoiding any surgical intervention. Close observation of daily echocardiograms might be helpful in detecting subclinical RHF and is useful for post-implant medical management.

IntroductionThe minimally invasive cardiac surgery off-pump coronary artery bypass (MICSOPCAB) is technically difficult; therefore, previous studies have indicated that MICSOPCAB should be contraindicated in patients with impaired left ventricular (LV) function. In this study, we investigated the feasibility of MICSOPCAB in patients with impaired LV function.MethodsThe 226 patients underwent MICSOPCAB between August 2017 and September 2022. Our study defined impaired LV function as ejection fraction (EF) in echocardiography 40% or less. The patients were divided into Low EF group (n = 39) and Normal EF group (n = 187).ResultsThe Low EF group was in a more critical preoperative condition than Normal EF group (41.0% in the Low EF group vs. 14.4% in the Normal EF group; p

Introduction: During stent grafting, managing the internal iliac artery (IIA) becomes a significant issue when an abdominal aortic aneurysm (AAA) is complicated by bilateral common iliac artery (CIA) aneurysms. The iliac branch system (IBS) has a defined length; therefore, the CIA should be sufficiently long. However, situations arise where the IBS must be used even in patients with a short CIA. A case of contralateral CIA occlusion due to deviation of the proximal iliac branched component of the IBS is reported. Report: A 73 year old man underwent stent grafting with inferior mesenteric artery coil embolisation and IBS for a 70 mm AAA and >30 mm bilateral CIA aneurysm. As standard procedure, the right iliac branched component and the internal iliac component were used. After removing the guidewire used for deploying the internal iliac component, the left 12 Fr Dryseal and guidewire were pulled down. The proximal end of the right iliac branched component deviated over the left CIA origin, resulting in CIA occlusion. As a solution, a 12 Fr Dryseal was inserted with a dilator and guidewire in the 16 Fr Dryseal from the left side, following which the tip of the 12 Fr Dryseal dilator was used to push the iliac branched component to create a gap. The guidewire was successfully inserted, and the surgery was subsequently completed as planned. The post-operative course of the patient was uneventful. Conclusion: When deploying an iliac branched component in cases where the CIA is shorter than the length of the component, it is crucial to place the contralateral guidewire into the aorta before pulling down the contralateral sheath. The iliac branched component may follow the pull through wire and occlude the contralateral CIA. Furthermore, if the element occludes the contralateral CIA, it can be managed using this method.

Abstract Background Single-stranded (ss) DNAs are utilized in various molecular biological and biotechnological applications including the construction of double-stranded DNAs with a DNA lesion, and are commonly prepared by using chimeric phage-plasmids (phagemids) plus M13-derived helper phages. However, the yields of ss DNA with these methods are poorly reproducible, and multiple factors must be optimized. Results In this report, we describe a new arabinose-inducible ss phagemid production method without helper phage infection. The newly exploited DNA derived from VCSM13 expresses the pII protein, which initiates ss DNA synthesis, under the control of the araBAD promoter. In addition, the packaging signal is deleted in the DNA to reduce the contamination of the phage-derived ss DNA. The phagemid DNA of interest, carrying the M13 origin of replication and the packaging signal, was introduced into bacterial cells maintaining the modified VCSM13 DNA as a plasmid, and the ss phagemid DNA production was induced by arabinose. The DNA recovered from the phage particles had less contamination from VCSM13 DNA, as compared to the conventional method. Moreover, we extended the method to purify the ss DNAs by using an anion-exchange column, to avoid the use of hazardous chemicals. Conclusion Using this combination of methods, large quantities of phagemid ss DNAs of interest can be consistently obtained.

Superior mesenteric artery (SMA) aneurysms (SMAAs) are rare and account for approximately 7% of all visceral artery aneurysms. If the anatomical complexity permits and the patency of organ perfusion is allowed, then an endovascular approach is the first choice for minimally invasive procedures. We report the case of a 92-year-old female with a giant SMAA and challenging anatomy, including a short proximal sealing zone from the origin of the SMA and a short distal sealing zone from the hepatic artery bifurcation. In view of her advanced age, she was treated endovascularly with covered stents. Reintervention was required to correct a postoperative endoleak; however, a favorable outcome was achieved with endovascular therapy.

Abstract Background Anesthetic management of thoracic aortic aneurysms (TAAs) is sometimes difficult due to fatal complications, including hypovolemic shock secondary to aneurysm rupture. We report the successful management of an impending rupture of a TAA with associated esophageal stenosis and compression of the pulmonary artery and left bronchi. Case presentation An 83-year-old woman, diagnosed with an impending rupture of the ascending TAA, was scheduled to undergo emergency total aortic arch replacement. Computed tomography showed esophageal stenosis with significant amounts of food residues in the thoracic esophagus and compression of the pulmonary artery and bronchi. We performed awake intubation and superior laryngeal nerve block with light sedation to prevent aspiration and aneurysmal rupture, respectively. General anesthesia was induced immediately after the intubation. No intraoperative complications occurred. Conclusions Performing awake intubation with a superior laryngeal nerve block and sedation may prevent aspiration of food residues and hemodynamic changes that may lead to rupture.

Objective: To identify whether preoperative magnetic resonance imaging findings of the brain can predict postoperative delirium in patients who undergo arch replacement for aneurysms. Methods: Overall, 193 patients who underwent aortic replacement for the first time at a single institution between April 2014 and September 2020 were enrolled in this retrospective study. After we excluded patients with acute aortic dissection, no preoperative magnetic resonance imaging findings of the brain, and postoperative cerebral infarction, 50 patients were included and divided into 2 groups, according to their confusion scale results: postoperative delirium (group D) and nonpostoperative delirium (group ND). Preoperative magnetic resonance imaging findings of the brain were classified into lacunar stroke, periventricular hyperintensity, and deep subcortical white matter hyperintensity groups; the latter 2 groups were further classified based on the Fazekas scale, grade 0 to 3. Results: There were 23 patients (46%) in group D and 27 (54%) in group ND. The mean age was significantly greater in group D than in group ND (75 vs 70 years; P = .007). The mean operative time was significantly longer in group D than in group ND (447 vs 384 minutes; P = .024). As for preoperative magnetic resonance imaging findings of the brain, there were significantly more lacunar stroke cases in group D than in group ND (P = .027). In multivariable logistic regression with stepwise selection, high-grade periventricular hyperintensity was significantly related to postoperative delirium (odds ratio, 9.38; 95% confidence interval, 1.55-56.56; P = .015). Conclusions: Silent cerebral ischemia detected by preoperative magnetic resonance imaging of the brain was a significant risk factor for postoperative delirium.

ObjectiveThis study aimed to compare the short- and long-term outcomes of proximal repair vs. extensive arch surgery for acute DeBakey type I aortic dissection.SubjectsFrom April 2014 to September 2020, 121 consecutive patients with acute type A dissection were surgically treated at our institute. Of these patients, 92 had dissections extending beyond the ascending aorta.MethodsOf the 92 patients, 58 underwent proximal repair, including aortic root and/or hemiarch replacement, and 34 underwent extended repair, including partial and total arch replacement. Perioperative variables and early and late postoperative results were statistically analyzed.ResultsThe duration of surgery, cardiopulmonary bypass, and circulatory arrest was significantly shorter in the proximal repair group (p

Background: Off-pump coronary artery bypass grafting has not been standardized in Southeastern Asian countries because it is technically demanding. However, this method could be suitable for economically disadvantaged institutions because it saves cost on the heart–lung machine. We summarized our results to assess the validity of our early introduction of this method. Methods: We reviewed the data from 750 patients who underwent off-pump coronary artery bypass grafting at our institution. Before the introduction of off-pump coronary artery bypass grafting, experts from Japan were enlisted to teach our surgeons technicalities of the procedure. The primary outcome was in-hospital mortality, and secondary outcomes included any major adverse cardiac or cerebrovascular event. Results: The in-hospital mortality rate was 1.5%. The rates of survival and freedom from major adverse cardiac or cerebrovascular event 3 years after the operation were 92.5% ± 1.8% and 90.7% ± 2.2%, respectively. In the multivariable analysis, the independent risk factors for major adverse cardiac or cerebrovascular event were chronic obstructive pulmonary disease (adjusted hazard ratio = 2.35, 95% confidence interval = 1.35–4.10, P = .003) and renal insufficiency (adjusted hazard ratio = 2.70, 95% confidence interval = 1.52–4.80, P = .001), whereas risk factors for in-hospital death were pump conversion (relative risk = 17.4, 95% confidence interval = 1.63–4.41, P

With an incidence of 3 in 100 million, giant coronary artery aneurysm (CAA) with coronary artery fistula (CAF) is a very rare condition. To prevent rupture, giant CAA with CAF should be swiftly treated. We present a Jehovah's Witness patient with giant CAA and coronary-pulmonary artery fistula. We resected the giant CAA in one piece, while ligating the CAF, without allogeneic blood transfusion. Due to rarity of these conditions, many thoracic surgeons lack direct experience in its surgical procedures. Herein, we share footage of this surgery as an example of how to safely resect CAA with minimal bleeding.

Background: Achieving external access to and manual occlusion of the left atrial appendage (LAA) during minimally invasive mitral valve surgery (MIMVS) through a small right thoracotomy is difficult. Occlusion of the LAA using an epicardial closure device seems quite useful compared to other surgical techniques. Methods: Fourteen patients with atrial fibrillation underwent MIMVS with concomitant surgical occlusion of the LAA using double-layered endocardial closure stitches (n=6, endocardial suture group) or the AtriClip Pro closure device (n=8, AtriClip group) at our institution. The primary safety endpoint was any device-related adverse event, and the primary efficacy endpoint was successful complete occlusion of blood flow into the LAA as assessed by transthoracic echocardiography at hospital discharge. The primary efficacy endpoint for stroke reduction was the occurrence of ischemic or hemorrhagic neurologic events. Results: All patients underwent LAA occlusion as scheduled. The cardiopulmonary bypass and aortic cross-clamp times in the endocardial suture group and the AtriClip group were 202±39 and 128±41 minutes, and 213±53 and 136±44 minutes, respectively (p=0.68, p=0.73). No patients in either group experienced any device-related serious adverse events, incomplete LAA occlusion, early postoperative stroke, or neurologic complication. Conclusion: Epicardial LAA occlusion using the AtriClip Pro during MIMVS in patients with mitral valve disease and atrial fibrillation is a simple, safe, and effective adjunctive procedure.

Abstract Background Coagulopathy and following massive bleeding are complications of cardiovascular surgery, particularly occurring after procedures requiring prolonged cardiopulmonary bypass (CPB). Reliable and rapid tests for coagulopathy are desirable for guiding transfusion. Measuring multiple coagulation parameters may prove useful. The purpose of this study is to determine the laboratory parameters predicting massive bleeding. Methods In a prospectively collected cohort of 48 patients undergoing cardiovascular surgery, markers of coagulation and fibrinolysis were measured using automated analyzer and their correlations with bleeding volume were determined. Results Operation time was 318 (107–654) min. CPB time was 181 (58–501) min. Bleeding volume during surgery was 2269 (174–10,607) ml. Number of transfusion units during surgery were packed red blood cells 12 (0–30) units, fresh frozen plasma 12 (0–44) units, platelets 20 (0–60) units and intraoperative autologous blood collection 669 (0–4439) ml. Post-surgery activities of coagulation factors II (FII), FV, FVII, FVIII, FIX, FX, FXI and FXII were decreased. Values of fibrinogen, antithrombin, α2 plasmin inhibitor (α2PI) and FXIII were also decreased. Values of thrombin-antithrombin complex (TAT) were increased. Values of FII, FIX, FXI and α2PI before surgery were negatively correlated with bleeding volume (FII, r = − 0.506: FIX, r = − 0.504: FXI, r = − 0.580; α2PI, r = − 0.418). Level of FIX after surgery was negatively correlated with bleeding volume (r = − 0.445) and level of TAT after surgery was positively correlated with bleeding volume (r = 0.443). Conclusions These results suggest that several clinical and routine laboratory parameters of coagulation were individually associated with bleeding volume during cardiovascular surgery. Determining the patterns of coagulopathy may potentially help guide transfusion during cardiovascular surgery.

A forward mutagenesis assay using the supF gene has been widely employed for the last several decades in studies addressing mutation frequencies and mutation spectra associated with various intrinsic and environmental mutagens. In this study, by using a supF shuttle vector and non-SOS-induced Escherichia coli with short-read next-generation sequencing (NGS) technology, we present an advanced method for the study of mutations, which is simple, versatile, and cost-effective. We demonstrate the performance of our newly developed assay via pilot experiments with ultraviolet (UV) irradiation, the results from which emerge more relevant than expected. The NGS data obtained from samples of the indicator E. coli grown on titer plates provides mutation frequency and spectrum data, and uncovers obscure mutations that cannot be detected by a conventional supF assay. Furthermore, a very small amount of NGS data from selection plates reveals the almost full spectrum of mutations in each specimen and offers us a novel insight into the mechanisms of mutagenesis, despite them being considered already well known. We believe that the method presented here will contribute to future opportunities for research on mutagenesis, DNA repair, and cancer.

ObjectiveSecure proximal anastomosis is an essential part of surgical treatment for acute aortic dissection type A (AADA). This study aimed to investigate the effectiveness of the modified turn-up technique for proximal anastomosis in AADA and compare this technique with other techniques.MethodsWe divided 57 patients who underwent ascending aorta replacement for AADA into the modified turn-up technique group (group A: 36 patients) and the other technique group (group B: 21 patients). Intraoperative and postoperative course data were compared between groups A and B. In group A, we also compared early-career surgeons (practicing for

The low patency of synthetic vascular grafts hinders their practical applicability. Polyvinyl alcohol (PVA) is a non-toxic, highly hydrophilic polymer; thus, we created a PVA-coated polycaprolactone (PCL) nanofiber vascular graft (PVA–PCL graft). In this study, we examine whether PVA could improve the hydrophilicity of PCL grafts and evaluate its in vivo performance using a rat aorta implantation model. A PCL graft with an inner diameter of 1 mm is created using electrospinning (control). The PCL nanofibers are coated with PVA, resulting in a PVA–PCL graft. Mechanical property tests demonstrate that the PVA coating significantly increases the stiffness and resilience of the PCL graft. The PVA–PCL surface exhibits a much smaller sessile drop contact angle when compared with that of the control, indicating that the PVA coating has hydrophilic properties. Additionally, the PVA–PCL graft shows significantly less platelet adsorption than the control. The proposed PVA–PCL graft is implanted into the rat’s abdominal aorta, and its in vivo performance is tested at 8 weeks. The patency rate is 83.3% (10/12). The histological analysis demonstrates autologous cell engraftment on and inside the scaffold, as well as CD31/α-smooth muscle positive neointima regeneration on the graft lumen. Thus, the PVA–PCL grafts exhibit biocompatibility in the rat model, which suggests that the PVA coating is a promising approach for functionalizing PCL.

Abstract Introduction Acute exacerbation (AE) is a devastating phenomenon and reported to be complicated with systemic autoimmune disease-associated interstitial lung disease (ILD). The aim of this study was to investigate the incidence and prognosis of AE of systemic autoimmune disease-ILD and clarify relevant clinical information predictive of these outcomes. Method This study was designed as a systematic review and meta-analysis. A primary study except for a case report, which reported the incidence and/or prognosis of AE of systemic autoimmune disease-ILD, was eligible for the review. Electronic databases such as Medline and EMBASE were searched from 2002 through 23 February 2020. Two reviewers independently selected eligible reports and extracted relevant data. Risk of bias of individual studies was assessed similarly. The incidence and prognosis of the disease were analysed qualitatively. Univariate results of risk and prognostic factors were combined if feasible. Results Out of a total of 2662 records, 24 studies were eligible. A total of 420 subjects with 45.7% of men developed AE of systemic autoimmune disease-ILD and the two major underlying systemic autoimmune diseases were rheumatoid arthritis (34.2%) and polymyositis/dermatomyositis (31.9%). The frequency ranged from 4.3 to 32.9% with the incident rate being 3.19 and 5.77 per 100 patient-years and all-cause mortality was between 30.0 and 58.3% at 90 days. Age at initial presentation was significantly associated with the development of AE of systemic autoimmune disease-ILD with an HR of 1.22 (95%CI 1.05–1.50) while a percentage of predicted diffusing capacity of the lung for carbon monoxide (%DLCO) was also significantly associated with the development of the disease with an HR of 0.95 (95%CI 0.90–1.00) and an OR of 0.97 (95%CI 0.95–0.99). Partial pressure of arterial oxygen/fraction of inspired oxygen ratio (PaO2/FiO2) at AE was significantly associated with all-cause mortality of AE of systemic autoimmune disease-ILD with an HR of 0.99 (95%CI 0.98–0.99). Conclusion AE of systemic autoimmune disease-ILD was not uncommon and demonstrated dismal prognosis. Age at initial presentation and %DLCO were deemed as risk factors while PaO2/FiO2 at AE was considered as a prognostic factor of the disease. Registration CRD42019138941.

Abstract Background In adult patients with primary or recurrent coarctation of the aorta (CoA), extra-anatomic bypass grafting (EABG) has been widely used as a surgical treatment option. However, there have been few reports on pseudoaneurysms (PAs) of the distal anastomotic sites after extra-anatomic bypass for CoA. Case presentation A 51-year-old man with hemoptysis was transferred to our hospital. Twenty years ago, he had undergone EABG from the ascending to the descending aorta (ascending-to-descending EABG) for CoA with right aortic arch. Eight years ago, he underwent thoracic endovascular aortic repair (TEVAR) for the ruptured PA on the distal anastomotic site of the EABG. Contrast-enhanced computed tomography scans revealed recurrent ruptured PA on the distal anastomotic site of the EABG. Therefore, we decided to replace the descending aorta, followed by end-to-side anastomosis of the EABG to the replaced descending aorta. However, due to massive adhesion of the lung to the EABG and PA, we performed transection of the descending aorta to decompress the PA. The postoperative course was uneventful, and the patient is doing well 5 months after surgery. Conclusions Aortic transection between the CoA and the distal anastomosis site may be a useful additional procedure in patients previously treated with TEVAR for PAs in the distal anastomosis site after EABG.

PurposeThe effect of chronic limb threatening ischemia (CLTI) on advanced cardiac disease, which requires surgical treatment, has rarely been reported. The purpose of this study was to review the outcomes of cardiac surgery in patients with CLTI and determine the risk factors, with a particular focus on the severity of CLTI.PatientsThe baseline characteristics and outcomes of 33 patients who were treated for CLTI and underwent cardiac surgery were retrospectively analyzed. The states of CLTI were evaluated based on the Wound, Ischemia, and foot Infection (WIfI) classification system, and 33 patients were divided into the low-WIfI group (stages 1–2, n = 13) and high-WIfI group (stages 3–4, n = 20).ResultsThe in-hospital mortality rate was 0% in low-WIfI group and 35% in high-WIfI group (p = 0.027). Postoperative complications, particularly severe infections, occurred more frequently among high-WIfI group than low-WIfI group (70.0% vs. 23.1%, p

Abstract Background The supF gene of Escherichia coli is useful for forward mutation analysis in bacterial and mammalian cells used in mutagenesis and DNA repair studies. Indicator E. coli strains, such as KS40/pOF105, have been used to analyze supF mutations. However, KS40/pOF105 is not enough to select supF mutants on nutrient-rich agar plates. Therefore, in this study, a new indicator E. coli strain for rapid and accurate detection of supF mutations was developed. Results The gyrA and rpsL genes with an amber mutation were integrated into the chromosomal DNA of E. coli KS40 to produce a new indicator strain, RF01. RF01 cells transformed by the wild-type supF gene were sensitive to nalidixic acid and streptomycin on LB agar plates. supF mutant frequencies and mutation spectra in RF01 were similar to those in KS40/pOF105. In addition, some mutations in supF were only detected in RF01. Conclusion RF01 is a new and useful indicator E. coli strain for analyzing supF mutations.

Abstract Background Pulmonary vein stenosis or occlusion is a rare but one of the most devastating complications after catheter ablation for cardiac arrhythmias, and surgical repair is an option in severe cases. The sutureless technique, which avoids direct suture of vessel walls, was initially described for congenital pulmonary vein stenosis and has been widely performed due to its good restenosis-free rate. Case presentation A 52-year-old male developed left pulmonary vein occlusion after catheter ablation for atrial fibrillation. The surgical repair with sutureless technique using the left atrial appendage was performed without any complications. Postoperative computed tomography demonstrated the revascularization of the pulmonary vein. Conclusions The sutureless technique using the left atrial appendage is significantly reasonable particularly in case of left pulmonary vein stenosis or occlusion after catheter ablation for atrial fibrillation since it reduces the risks of restenosis and thromboembolism.

Abstract Background Acute exacerbation (AE) of idiopathic pulmonary fibrosis (IPF) is devastating with no established treatment. This phenomenon involves disordered coagulation and excessive inflammatory reactions. As recombinant human soluble thrombomodulin (rhsTM) possesses anti-coagulative and anti-inflammatory properties, the medicine is expected to improve the prognosis of the disease. The aim of this study was to summarize current evidence regarding benefits and harms of rhsTM treatment for AE of IPF. Method Patients with AE of IPF were eligible for the review and all of the other types of interstitial pneumonias were excluded. The effect of rhsTM treatment on the outcomes such as all-cause mortality was estimated in comparison to conventional therapy. Primary studies of any design aside from a case report were reviewed. Electronic databases such as Medline and EMBASE were searched from 2002 through August 14, 2019. Two reviewers independently selected eligible reports and extracted relevant data. A risk of bias of individual studies was assessed similarly. Meta-analysis was conducted for univariate results if at least three studies were available for the same outcome. Result Out of a total of 390 records identified, eight studies were first deemed eligible and four of them were finally focused for the review. Only one study was a prospective trial and a historical control was employed in all studies. An overall risk of bias was rated as serious in three out of four studies. A total of 169 subjects were included. Two out of three studies that reported 3-month all-cause mortality by univariate analysis demonstrated beneficial effects of rhsTM treatment and a pooled analysis demonstrated that rhsTM treatment improved 3-month all-cause mortality with a risk ratio of 0.50 (95% confidence interval (CI): 0.35–0.72). All two studies reporting multivariate results demonstrated that rhsTM treatment improved 3-month all-cause mortality with odds ratios of 0.21 (95% CI: 0.05–0.91) and 0.25 (95% CI: 0.09–0.68), respectively. There were no serious adverse events. Conclusion The rhsTM treatment was demonstrated to improve 3-month all-cause mortality of AE of IPF with no serious adverse events. However, these findings should be interpreted with caution due to a small number of studies and serious risk of bias.

BackgroundsMinimally invasive mitral valve surgery (MIMVS) in patients with a small body presents surgeons with a technically difficult surgical maneuver. We hypothesized that physique might negatively influence the safety and technical complexity of MIMVS.MethodsOne hundred and twenty-one patients underwent MIMVS in our institution between May 2014 and April 2020. These patients were categorized into two groups. The first group was the small physique group (n = 20) consisting of patients with a stature 150 cm. The primary endpoint was freedom from death and major adverse cardiovascular and cerebrovascular events (MACCE). The secondary endpoint was freedom from moderate or severe mitral regurgitation.ResultsCardiopulmonary bypass time (130 ± 29 vs. 156 ± 55 min, p = 0.02) and aortic cross-clamp time (75 ± 27 vs. 95 ± 39 min, p = 0.03) were significantly shorter in the small physique group. Both in the early and midterm periods, there was no significant difference in the mortality (early, 5.0 vs. 1.0%, p = 0.30. midterm, 5.0 vs. 1.0%, p = 0.09), MACCE (early, 5.0 vs. 6.9%, p = 0.65. midterm, 5.0 vs. 5.9%, p = 0.93) and the residual MR (early, 0 vs. 1.0%, p = 0.66. midterm, 5.0 vs. 4.9%, p = 0.93) between the two groups.ConclusionsSmall physique is not a hurdle for MIMVS in terms of the safety of the operation.

Abstract Environmental factors can inhibit DNA repair and cause indirect mutagenic actions. Here the author introduces a recent paper on a novel high-throughput system to analyze the various enzymatic activities involved in base excision repair. Such systems will facilitate the identification of compounds that suppressively affect DNA repair.

Introduction: To facilitate safe anastomosis of a vascular prosthesis onto the proximal ascending aorta without side clamping, a clampless anastomotic device with large diameter aortic puncher was developed. Report: First, a vascular prosthesis is anastomosed onto the aorta without making a hole, then the aortic wall within the prosthesis is punched out using the device. Discussion: After further refinement of the present device, endovascular surgery with debranching could be performed more safely and quickly.

Objective To clarify the risk of rheumatoid arthritis-associated interstitial lung disease (RA-ILD) related to anti-cyclic citrullinated peptide (CCP) antibody.Eligibility criteria Patients with RA with and without ILD were eligible. The primary outcome was the prevalence or incidence of ILD. Primary studies of any design aside from a case report were eligible.Information sources Medline, EMBASE, Science Citation Index Expanded and Cochrane Central Register of Controlled Trials were searched from the inception through 12 November 2019.Data extraction and risk of bias Two reviewers independently selected eligible reports, extracted relevant data and assessed risk of bias using a modified Quality in Prognostic Studies tool.Data synthesis Meta-analysis was conducted using a random-effects model.Quality of evidence The Grades of Recommendation, Assessment, Development and Evaluation system was applied.Results Among 29 out of 827 records retrieved through electronic databases and four additional reports identified from other sources, 29 studies were focused for the review. A total of 10158 subjects were included and the mean age at inclusion was between 45.8 and 63.9 years. The mean RA duration was between 4.3 and 14.9 years. The positivity of anti-CCP antibody ranged from 50.7% to 95.8%. All studies except for two were deemed as high risk of bias. A pooled analysis of univariate results demonstrated that the presence of anti-CCP antibody was significantly associated with RA-ILD with an OR of 2.10 (95% CI: 1.59 to 2.78). Similarly, the titre of anti-CCP antibody was significantly higher for RA-ILD with a standardised mean difference of 0.42 (95% CI: 0.20 to 0.65). These results were confirmed by multivariate analysis in the majority of studies and consistent by any subgroup and sensitivity analyses.Conclusion The presence and higher titres of anti-CCP antibody were suggested to be significantly associated with an increased risk of RA-ILD. However, the quality of evidence was rated as low or very low.

Cardiovascular disease is the most common cause of death in the world. In severe cases, replacement or revascularization using vascular grafts are the treatment options. While several synthetic vascular grafts are clinically used with common approval for medium to large-caliber vessels, autologous vascular grafts are the only options clinically approved for small-caliber revascularizations. Autologous grafts have, however, some limitations in quantity and quality, and cause an invasiveness to patients when harvested. Therefore, the development of small-caliber synthetic vascular grafts (

An anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital heart disease. Among the variants, an anomalous origin of the left anterior descending coronary artery from the pulmonary artery (ALADPA) is extremely rare. Here, we report a case of ALADPA in an adult that was treated with coronary artery bypass grafting using the left internal thoracic artery.

Transcatheter aortic valve replacement has become a popular choice for cases with severe aortic stenosis. However, when severe mitral regurgitation is comorbid in high-risk patients with severe aortic stenosis, therapeutic options must be weighed for each case. Here we present a very frail 88-year-old patient with severe aortic stenosis and severe mitral valve regurgitation who underwent a successful awake minimally invasive mitral valve repair after transcatheter aortic valve replacement.

This case report details the management of a 79-year-old man who developed massive postoperative pneumothorax following redo coronary artery bypass grafting due to severe lung adhesions. We successfully treated the patient using veno-venous extracorporeal membrane oxygenation without femoral cannulation, allowing for early rehabilitation initiation. Veno-venous extracorporeal membrane oxygenation is a reasonable option for cases of severe respiratory failure due to pneumothorax with lung destruction caused by re-sternotomy during re-do cardiac surgery. [ABSTRACT FROM AUTHOR]

The Polycomb repressive complex 2 (PRC2) is a multicomponent histone H3K27 methyltransferase complex, best known for silencing the Hox genes during embryonic development. The Polycomb-like proteins PHF1, MTF2, and PHF19 are critical components of PRC2 by stimulating its catalytic activity in embryonic stem cells. The Tudor domains of PHF1/19 have been previously shown to be readers of H3K36me3 in vitro. However, some other studies suggest that PHF1 and PHF19 co-localize with the H3K27me3 mark but not H3K36me3 in cells. Here, we provide further evidence that PHF1 co-localizes with H3t in testis and its Tudor domain preferentially binds to H3tK27me3 over canonical H3K27me3 in vitro. Our complex structures of the Tudor domains of PHF1 and PHF19 with H3tK27me3 shed light on the molecular basis for preferential recognition of H3tK27me3 by PHF1 and PHF19 over canonical H3K27me3, implicating that H3tK27me3 might be a physiological ligand of PHF1/19.

Hemoptysis after thoracic endovascular/open aortic repair is relatively rare but a well-known complication, and normally diagnosed with aortobronchial fistula (ABF). Here, we present a patient who suffered from recurrent massive hemoptyses even after multiple thoracic endovascular aortic repairs (TEVARs), where hemoptysis was ultimately controlled by pneumonectomy. In this case, the bleeding source was not the aorta but the lung parenchyma itself, indicating the importance of raising awareness that the cause of massive hemoptysis after TEVAR may not always be an ABF.

Objective To clarify prognostic factors of acute exacerbation (AE) of idiopathic pulmonary fibrosis (IPF).Design A systematic review and meta-analysis.Data sources Medline, Embase and Science Citation Index Expanded were searched from 2002 through 1 March 2019.Eligibility criteria for selecting studies The review included primary studies addressing the association between the outcomes such as all-cause mortality of AE of IPF and its potential prognostic factors, which were designated as any clinical information related to the outcomes.Data extraction and synthesis Two reviewers extracted relevant data independently and assessed risk of bias. Univariate results were pooled using a random-effect model if at least three studies were available. Prognostic factors were determined based on significant and consistent results on both univariate and multivariate analyses in the majority of studies.Results Out of a total of 6763 articles retrieved, 37 were eligible and 31 potential prognostic factors for all-cause mortality were selected. Each study was subject to certain methodological shortcomings. The following five factors were statistically significant by a meta-analysis of univariate results, which was confirmed by multivariate analysis, that is, Acute Physiology and Chronic Health Evaluation (APACHE) II score (HR 1.10, 1.01 to 1.19), partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) ratio (ORs 0.99 in two studies and HRs 0.31 and 0.99 in two studies, respectively), lactate dehydrogenase (LDH) (HRs 1.002, 1.003, 1.01 and 1.02), white blood cell (WBC) count (OR 1.38, 1.04 to 1.83) and oxygen therapy before AE (HRs 3.68, 1.05 to 12.9 and 2.34, 1.04 to 5.28) (multivariate analysis, 95% CI).Conclusions APACHE II score, PaO2/FiO2 ratio, LDH, WBC count and oxygen therapy before AE were deemed as prognostic factors of AE of IPF. Although there are some methodological limitations in this study, these findings are reliable due to consistent results by both univariate and multivariate analyses.PROSPERO registration number CRD42018106172.

Ribonucleoside triphosphates are often incorporated into genomic DNA during DNA replication. The accumulation of unrepaired ribonucleotides is associated with genomic instability, which is mediated by DNA topoisomerase 1 (Top1) processing of embedded ribonucleotides. The cleavage initiated by Top1 at the site of a ribonucleotide leads to the formation of a Top1-DNA cleavage complex (Top1cc), occasionally resulting in a DNA double-strand break (DSB). In humans, tyrosyl-DNA phosphodiesterases (TDPs) are essential repair enzymes that resolve the trapped Top1cc followed by downstream repair factors. However, there is limited cellular evidence of the involvement of TDPs in the processing of incorporated ribonucleotides in mammals. We assessed the role of TDPs in mutagenesis induced by a single ribonucleotide embedded into DNA. A supF shuttle vector site-specifically containing a single riboguanosine (rG) was introduced into the human lymphoblastoid TK6 cell line and its TDP1-, TDP2-, and TDP1/TDP2-deficient derivatives. TDP1 and TDP2 insufficiency remarkably decreased the mutant frequency caused by an embedded rG. The ratio of large deletion mutations induced by rG was also substantially lower in TDP1/TDP2-deficient cells than wild-type cells. Furthermore, the disruption of TDPs reduced the length of rG-mediated large deletion mutations. The recovery ratio of the propagated plasmid was also increased in TDP1/TDP2-deficient cells after the transfection of the shuttle vector containing rG. The results suggest that TDPs-mediated ribonucleotide processing cascade leads to unfavorable consequences, whereas in the absence of these repair factors, a more error-free processing pathway might function to suppress the ribonucleotide-induced mutagenesis. Furthermore, base substitution mutations at sites outside the position of rG were detected in the supF gene via a TDPs-independent mechanism. Overall, we provide new insights into the mechanism of mutagenesis induced by an embedded ribonucleotide in mammalian cells, which may lead to the fatal phenotype in the ribonucleotide excision repair deficiency.

Abstract Background Abasic sites are formed spontaneously and by nucleobase chemical modifications and base excision repair. A chemically stable abasic site analog was site-specifically introduced into replicable plasmid DNAs, which were transfected into human U2OS cells. The amplified DNAs were recovered from the cells and used for the transformation of a bacterial indicator strain. Results Large deletion mutations were induced by the analog, in addition to point mutations at the modified site. No apparent sequence homology at the deletion junctions was found. Conclusion These results suggested that the large deletions induced by the abasic site analog are formed by homology-independent events.

An emergency thoracic endovascular aortic repair (TEVAR) with zone 2 landing without revascularization of the left subclavian artery was performed due to the impending rupture of a distal arch aneurysm in an old patient presenting hemoptysis. Two months later, the patient had recurrent massive hemoptyses and continued after additional zone 0 TEVAR. The lung parenchyma was considered to be the bleeding source and transcatheter pulmonary artery embolization was performed, and the episodes of massive hemoptysis appeared to have ceased. However, the patient died of sudden recurrent massive hemoptysis 40 days later. Inflammation and/or infection of the lung parenchyma adjunct to the aortic aneurysm could be cause of fatal hemoptysis, and aggressive therapy such as lung resection should be considered in such patients.

Abstract Background Though several cases of upper gastrointestinal tract injury caused by transesophageal echocardiography (TEE) have been reported, gastric perforation is very rare. Herein, we report the case of TEE-associated gastric perforation that was successfully treated conservatively. Case presentation An 82-year-old man underwent mitral valve repair. Postoperative esophagogastroduodenoscopy and computed tomography revealed gastric perforation. Surgical treatment was initially considered, but conservative management was selected to avoid increasing operative stress, to minimize the need for total gastrectomy (including the lower esophagus), and to minimize the risk of a potential intraperitoneal infection spreading to the thoracic cavity. Conclusion Conservative management of gastric perforation can be successful even when the perforation is recognized later than 12 h following the event, provided that there are no abdominal symptoms and no signs of peritoneal effusion or sepsis. Our experience suggests that conservative management is a feasible option for treating TEE-associated gastric perforation in appropriately selected cases.

Abstract Ischemic stroke is uncommon in pediatric populations and is sometimes caused by cardiac myxoma. In such cases, neurological deficits initially present in ischemic stroke due to emboli or thrombi of the myxoma. Echocardiography is helpful to diagnose myxoma in a timely manner and allows urgent surgical resection of the myxoma. We report a successful case of myxoma in a 7-year-old boy who initially presented with left-sided hemiparesis.

Background: Although, in theory, valve-sparing aortic root replacement (David procedure) is an ideal surgical option for acute aortic dissection type A (AADA) it is usually not regarded as the first-choice treatment due to the emergency setting and the relative complexity of the procedure. Here, we report the results of a consecutive, single-surgeon series of 45 AADA patients with the David procedure as first-choice treatment strategy.Methods and Results: Between September 2009 and July 2013 a total of 49 patients with AADA were consecutively operated by the same surgeon at our institution. The David procedure was the treatment of choice for the proximal aorta unless aortic valve pathology or critical preoperative patient status advocated against it. Median follow-up was 5.0 years (CI95%, 4.0–6.0). Out of the 45 patients included in this study the David procedure was performed in 28 patients (62.2%), while in 17 patients (37.8%) an alternative surgical strategy had to be pursued. Although X-clamping (168.5 ± 41.7 vs. 110.3 ± 51.1 min; p = 0.001), cardiopulmonary bypass (CPB) (245.0 ± 62.4 vs. 211.8 ± 123 min; p = 0.029) and total operation time (383.8 ± 88.5 vs. 312.8 ± 144.8; p = 0.047) were significantly longer in the David-group as compared to the non-David group, there was no difference in major complication rate as well as 30-day (17.9 vs. 23.5%; p = 0.645) and 5-year mortality (28.6 vs. 35.3%) between groups.Conclusions: This small series indicates that the David procedure may be safe and feasible as a primary surgical treatment strategy for AADA.

Objectives: Rapidly progressive interstitial pneumonia is a fatal disease with no established therapeutic options. The aim of this systematic review is to clarify the efficacy of interstitial pneumonia treatment utilizing direct hemoperfusion with a polymyxin B–immobilized fibre column. Methods: All patients with adult-onset rapidly progressive interstitial pneumonia including acute exacerbation of underlying chronic interstitial pneumonia were eligible. Primary studies of any design, which compared outcomes of direct hemoperfusion with a polymyxin B–immobilized fibre column treatment such as oxygenation and all-cause mortality with those of conventional therapy, were included. Electronic databases such as Medline and EMBASE were searched through October 7, 2018, and ICHUSHI, the largest database for medical articles in Japan, was also searched. Two reviewers independently extracted the relevant data and assessed the risk of bias in individual studies. The results were reported qualitatively due to substantial heterogeneity between studies. Results: Out of 775 records retrieved, 10 reports were eligible and 8 of them were included for further analysis. They were all retrospective studies including a total of 327 patients and contained some risk of bias. There was variation in the administration method of direct hemoperfusion with a polymyxin B–immobilized fibre column treatment such as the timing, frequency, duration and interval. Multivariate analyses of only two studies with historical controls demonstrated beneficial effects of direct hemoperfusion with a polymyxin B–immobilized fibre column treatment over conventional therapy with all-cause mortality hazard ratios of 0.345 (95% confidence interval: 0.127–0.936) and 0.505 (95% confidence interval: 0.270–0.904), respectively. A significant difference of an improvement in the ratio of partial arterial oxygen pressure to the fraction of inspired oxygen in-between two treatment groups was also reported in two studies utilizing historical controls with mean differences of 56.8 and 57.5 mmHg, respectively. Conclusions: There is currently insufficient data to support the use of direct hemoperfusion with a polymyxin B–immobilized fibre column treatment for rapidly progressive interstitial pneumonia. It should be instituted for research purposes only until new evidence is available.

Nonbacterial thrombotic endocarditis (NBTE) on the aortic valve involves fibrin and platelet aggregate formation, potentially leading to embolic events. We present a case of NBTE on the aortic valve following coronary angiography (CAG) in a 54-year-old man with multiple comorbidities. Surgical thrombectomy was performed owing to acute cerebral infarcts. This case highlights the significance of considering that mechanical trauma from catheterization during CAG can trigger thrombus formation. [ABSTRACT FROM AUTHOR]

BackgroundCardiac redo surgery, especially after a full sternotomy, is considered a high-risk procedure. Minimally invasive mitral valve surgery (MIMVS) is a potential therapeutic approach. However, current developments in interventional cardiology necessitate additional discussion regarding the therapy of choice in high-risk patients. In this context, it is necessary to clarify the perioperative and postoperative risks induced by the factor previous sternotomy in the setting of MIMVS. Thus, we present a comparative study analyzing the outcome of MIMVS after previous sternotomy vs. primary operation.MethodsWe identified 19 patients who received isolated or combined mitral valve (MV) surgery via the MIMVS approach after previous full sternotomy (PS group) and compared the results to those of a group of 357 patients who received primary MIMVS (non-PS group). After a propensity score analysis, groups of n = 15 and n = 131, respectively, were subjected to a comparative evaluation. A 1-year follow-up analysis of functional cardiac parameters and clinical symptoms was performed, accompanied by a Kaplan–Meier analysis.ResultsExcept for the rate of realized MV reconstructions (PS group: 53.8% vs. non-PS group: 85.5%; p = 0.011), no significant differences were to be noted within the intraoperative and early postoperative course. However, patients in the PS group experienced an increased intensive care unit stay length (PS group: 2 days, 95% CI, 1–8 vs. non-PS group: 1 day, 95% CI, 1–2; p = 0.072). The follow-up examinations revealed excellent functional and clinical outcomes for both groups. The Kaplan–Meier analysis displayed no significant difference regarding the postoperative mortality (p = 0.929) related to the patients at risk.ConclusionA previous sternotomy remains a risk factor for MIMVS and demands special attention in the early postoperative period. Nevertheless, the early- and late-term results concerning the functional and clinical outcomes suggest that the MIMVS procedure is satisfactory, even after a full sternotomy.