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Purpose: To develop and assess a non-invasive two-step method for evaluating the relationship between the parietal pleura and peripheral pulmonary lesions to preoperatively exclude invasion or focal pleural adhesion by multidetector computed tomography (CT).Methods: Twenty-six patients with pulmonary peripheral lesions who underwent surgical lung resection between May and December 2017 were enrolled in this study. Routine CT was performed in the inspiratory phase in the supine position. Additional CT examinations were performed both in inspiratory and expiratory phases in the affected-side-up lateral position. Axial, sagittal, and coronal images were reconstructed from the CT data. In the first-step analysis, we evaluated the separation between the chest wall and subpleural lung lesions (separation) by comparing inspiratory- and expiratory-phase images obtained in the affected-side-up lateral position. When the separation was absent, we performed a second-step analysis, where we compared images obtained in the supine position during routine CT with those obtained in the affected-side-up lateral position and subsequently assessed the presence and absence of the separation.Results: In the first-step analysis, the separation was observed in 21 lesions, which were categorised as showing "no invasion" or "no focal adhesion" on the basis of histological findings. After the second-step analysis, the separation was absent in three lesions and present in two; the latter two lesions were categorised as showing "no invasion" or "no focal adhesion" on the basis of operative and histological findings. Of the three lesions that did not exhibit the separation in either step of the analysis, two were diagnosed as exhibiting parietal pleural invasion on the basis of histological findings, while the third was categorised as showing "no invasion" or "no focal adhesion" on the basis of operative and histological findings. The sensitivity, specificity, positive and negative predictive values, and accuracy of this two-step method were 96% (95% confidence interval [CI]: 79-100%), 100% (95% CI: 16-100%), 100%, 67% (95% CI: 23-93%), and 96% (95% CI: 80-100%), respectively.Conclusions: Our two-step method is especially useful for excluding the parietal pleural involvement of peripheral pulmonary lesions. Even when the separation between the chest wall and subpleural lung lesions was limited, the change in position was useful for observing the separation and excluding parietal pleural involvement. This novel two-step method also has the advantage of being simple, cost-effective, and universally available. [ABSTRACT FROM AUTHOR]

Introduction Salvage surgery for locoregional failures after definitive chemoradiotherapy (dCRT) for esophageal cancer is widely practiced, but treatment options complementing it are also needed due to the high morbidity and mortality and low rate of curative resection. Presentation of case A 58-year-old man with a surgical history of right upper lobectomy for lung cancer was diagnosed as having esophageal squamous cell carcinoma. Computed tomography revealed swelling of the lesser curvature lymph node, and it had invaded the stomach, the body and tail of the pancreas and the left gastric artery, splenic artery and celiac artery. The patient underwent definitive-dose radiation with chemotherapy. Complete response was attained for the primary tumor, but the metastatic lymph node infiltrating the stomach, pancreas and major vessels remained. Therefore, the Appleby operation was proposed to the patient and subsequently performed aiming at curability. However, the primary tumor recurred 38 months after surgery, so the novel modality of photodynamic therapy using talaporfin sodium and a diode laser was performed, and a complete response was attained for this lesion. The patient is alive at 50 months after the salvage Appleby operation. Discussion and conclusion Salvage lymphadenectomy for esophageal cancer may be insufficient as a curative treatment because of regrowth of the primary lesion. However, photodynamic therapy may be applicable as a curative treatment option for recurrence of the primary lesion after salvage lymphadenectomy. [ABSTRACT FROM AUTHOR]

Introduction We report a relatively rare case of esophageal leiomyoma in the upper thoracic esophagus enucleated by thoracoscopic procedures. The usefulness of preoperative diagnosis and an adequate surgical approach are described along with a review of the relevant literature. Presentaion of case A submucosal tumor 45 mm in diameter was detected in the upper thoracic esophagus of a 69-year-old man. The tumor was preoperatively diagnosed from histopathological biopsy under endoscopic ultrasound-guided fine needle aspiration. Thoracoscopic enucleation was therefore preoperatively scheduled under the left decubitus position in consideration of the low risk of malignant disease. Histopathological diagnosis of the resected specimen was benign leiomyoma and patient outcomes were good. Discussion The need for preoperative biopsy of esophageal submucosal tumor is a controversial issue. However, preoperative biopsy provided the benefits to decide the operative procedure or confirm adequate resection, and our experience suggested that preoperative biopsy did not adversely influence subsequent enucleation. Conclusion Precise preoperative diagnosis is necessary to avoid excessive surgery when managing esophageal submucosal tumor. [ABSTRACT FROM AUTHOR]

Background: The long-term results of mitral valve replacement (MVR; n = 631) with a bileaflet mechanical prosthesis or a Carpentier-Edwards Perimount bioprosthesis were evaluated in Japanese patients of different age groups. Methods: A total of 507 bileaflet mechanical prostheses and 124 bioprostheses have been implanted since 1982 at our institution. Follow-up was completed for 6,598 patient-years in 98.4% of the cases. Results: Among the patients 70 years of age and older, the rate of freedom from valve-related death and valve-related morbidity at 10 years after surgery were significantly better in the bioprostheses group (93.3% ± 6.4% and 83.7% ± 8.7%, respectively; n = 35) than in the mechanical prostheses group (71.1% ± 8.0% and 60.9% ± 8.9%, respectively; n = 82), and neither structural valve deterioration (SVD) nor resulting re-MVR were observed for bioprostheses. In contrast, among the patients 64 years and younger, no significant differences were observed in long-term survival between the mechanical prostheses group (n = 347) and the bioprostheses group (n = 76), while significantly lower rates of freedom from SVD and re-MVR were observed in the bioprostheses group compared with those obtained in the mechanical prostheses group. As for the controversial intermediate-age group of 65 to 69 years, the general tendencies were similar to those observed in the group 64 years and younger. Conclusions: Based on our comparative evaluation, bioprostheses should be chosen for MVR in patients 70 years of age and older, whereas mechanical prostheses were better in the patients 64 years of age and younger. The use of bioprostheses in Japanese patients 65 to 69 years of age is not preferable for preventing SVD and subsequent re-MVR. [Copyright &y& Elsevier]

Background: Clinical outcome of vascular bypass surgery using autologous vein graft is limited by neointimal formation associated with vein graft failure. Because inflammatory changes are one of the main pathologic features of vein graft failure, monocyte chemoattractant protein-1 (MCP-1) might therefore underlie in the mechanism of vein graft failure. There is no direct evidence, however, that shows the benefits of local anti-MCP-1 therapy as a novel molecular approach for prevention of vein graft failure. Methods: To block MCP-1, we used an N-terminal deletion mutant of the MCP-1 gene (7ND), which lacks the N-terminal amino acids 2 to 8, binds to its receptor CCR2, and blocks MCP-1-mediated monocyte chemotaxis. 7ND works as dominant-negative inhibitor of MCP-1. Autologous canine jugular vein grafts were transfected by incubating them ex vivo in a solution with or without adenovirus vectors containing 7ND gene or LacZ gene, and interposed into the carotid arteries. Results: Adenovirus-mediated gene transfer of 7ND, but not LacZ gene transfer, significantly attenuated inflammation (monocyte infiltration per mm2 on day 7: 328 ± 59, 220 ± 11, 26 ± 4 in control, LacZ, and 7ND groups, respectively, P < .05, n = 4 each) and proliferation (appearance of proliferating cells per mm2 on day 7: 1005 ± 186, 756 ± 106, 252 ± 27 in control, LacZ, and 7ND groups, P < .05, n = 4 each) at 7 days after the operation and thus suppressed neointimal formation (neointimal area in mm2 on day 28: 1.63 ± 0.51, 1.96 ± 0.48, 0.68 ± 0.10 in control, LacZ, and 7ND groups, P < .05, n = 4 each). This strategy also attenuated upregulation of MCP-1 activities but did not affect endothelial regeneration process. Conclusions: Blockade of MCP-1 by adenoviral gene transfer of 7ND limits neointimal formation associated with vein graft failure in dogs. This study highlights the potential therapeutic benefit of local anti-MCP-1 therapy for prevention of neointimal formation associated with vein graft failure. [Copyright &y& Elsevier]

Background: Angiotensin II type 1 (AT1) receptor antagonists may enhance the cyclic guanosine monophosphate-nitric oxide system and thereby attenuate ventricular and coronary endothelial dysfunction after heart preservation. Methods: We used an isolated rabbit heart preparation perfused with blood from a support rabbit. The rabbit heart was excised, stored for 24 hours, and then perfused with blood from a support rabbit that was treated with an AT1 receptor antagonist (telmisartan; 5 mg/kg) or solvent. We evaluated the cardiac output with the working preparation, and coronary blood flow and coronary endothelial function with the Langendorff preparation. In addition, we measured the serum nitric oxide level in the coronary effluent. Results: The Telmisartan Group showed higher plasma angiotensin II levels (928.6 ± 136.2 vs 271.6 ± 81.6 pg/ml, p < 0.01), better cardiac output (116.2 ± 5.4 vs 88.8 ± 7.1 ml/min, p < 0.05), and higher coronary blood flow (25.0 ± 2.2 vs 14.9 ± 1.3 ml/min, p < 0.01). The coronary blood flow in response to acetylcholine was higher in the Telmisartan Group (47.8 ± 3.9 vs 28.0 ± 2.1 ml/min, p < 0.01), but there was no difference in response to sodium nitroprusside. The Telmisartan Group showed higher serum nitric oxide levels in the coronary effluent (33.9 ± 4.6 vs 20.6 ± 3.3 μmol/liter, p < 0.05). Conclusions: Treatment with the AT1 receptor antagonist improved ventricular and endothelial function after 24-hour heart preservation. These data imply that AT1 activation plays a critical role in reperfusion injury. AT1 receptor blockade may be a promising strategy for long-term heart preservation. [Copyright &y& Elsevier]

Background: There are an increasing number of reports concerning mitral valve repair by means of reconstruction of the chordae tendinae with expanded polytetrafluoroethylene (e-PTFE) sutures. However little information is available about extended application or results of this technique for extended prolapse of posterior mitral leaflets.Methods: Between March 1994 and December 2000, 22 patients with moderate-to-severe mitral regurgitation (MR) as the result of a prolapse of posterior leaflets (age range, 39–73 years) underwent mitral valve repair by means of reconstruction of artificial chordae with 4-CV e-PTFE sutures without leaflet resection. Either Kay''s suture or ring annuloplasty was also performed to correct annular dilatation in all patients.Results: No operative death or late mortality was observed. Before discharge immediate postoperative echocardiography indicated less than moderate MR in 20 out of 22 patients. The follow-up was complete in all cases by clinical examination and serial echocardiograms and the median follow-up period was 87 months (range 24–108). There were two failures that required reoperation because of unsuccessful repair and worsening MR (elongation of the anchored side of the papillary muscle). When the reoperated patients were excluded from the follow-up data, the degree of MR, estimated by echocardiography that was performed at a recent follow-up period, was nonexistent in 6 patients, trivial in 10 patients, and mild in 4 patients. The systolic and diastolic dimensions of the left ventricle decreased significantly (p < 0.01).Conclusions: Replacement of the artificial chordae was not complicated and seemed to preserve favorable relationships among leaflet tissues, chordae, and papillary muscles. We therefore suggest that the extensive use of PTFE artificial chordae seems to be a promising procedure regarding the repair of many kinds of mitral lesions causing MR. [Copyright &y& Elsevier]

The purpose of this study was to assess the outcome of nonobstructive (or non–flow-limiting) residual dissection (RD) after percutaneous coronary intervention. Results of 124 consecutive native coronary lesions with angiographic nonobstructive RD in 97 patients (RD group) were compared with outcomes of 124 lesions without RD in 100 patients (non-RD group), whose characteristics were matched with those of the RD group. RD occurred after stent implantation (81 of 124 lesions, 65%) or balloon angioplasty (43 of 124 lesions, 35%). Angiographic types of RD were type A in 8 lesions (6%), B in 101 (82%), and C in 15 (12%). Stents were implanted in 65% of the lesions in each group. Clinical success (94% in RD group vs 95% in non-RD group, p = 0.77) and the in-hospital major adverse cardiac event rates were found to be similar in the 2 groups (6% vs 3%, respectively; p = 0.33). The late angiographic and clinical outcomes were also comparable. By intravascular ultrasound (IVUS) evaluation of the dissections in the RD group, area stenosis correlated with the incidence of in-hospital major adverse cardiac events (p = 0.023), whereas the final minimal lumen area correlated inversely with the occurrence of restenosis (p = 0.011). An area stenosis ≥58% was the best predictor for the incidence of in-hospital major adverse cardiac events (sensitivity 0.68, specificity 0.68). Most nonobstructive RDs are “favorable” and do not need stent implantation. IVUS evaluation identifies “unfavorable” nonobstructive (or non–flow-limiting) dissections that might be prone to acute occlusion. Nonobstructive dissections can be left untreated when final IVUS reveals an area stenosis of <60% at the site of a dissection. [Copyright &y& Elsevier]

Duodenal adenocarcinoma is a rare malignancy; recently, it has been found to be accompanied by operative indications. Nine consecutive rare cases were diagnosed with duodenal carcinoma (DC), in which clinicopathological characteristics were retrospectively examined. Age was ranged over middle-aged males and females. No clinical onset with severe symptoms was observed, and the specific treatment for accompanied diseases or habits was not found. One case of two T1 stage DCs that underwent pancreas-sparing duodenectomy. Stage II DC was diagnosed in three cases, and stage III DC was diagnosed in four cases. Pancreaticoduodenectomy (PD) mainly occurred in seven patients, and duodenectomy was limited in two patients. All operations were safely performed, and the postoperative course showed no severe morbidity. Histological findings showed R0 resection in eight cases and R1 at the retroperitoneal dissecting part in one case. Five patients with advanced-stage DC underwent adjuvant chemotherapy; however, four patients showed tumor recurrence within 12 months. With additional strong chemotherapy, eight patients survived up to 84 months, and one died of liver metastasis at 43 months after surgery. Three representative cases of mucosal invasion with widespread pancreas-sparing duodenectomy and advanced-stage DC cases undergoing duodenectomy or PD are shown. In the field of upper digestive tract surgery, duodenal adenocarcinoma and various applications of surgery or adjuvant chemotherapy for long-term survival are important. • Duodenal cancer used to be rare disease and, however, we have increasingly experienced surgical intervention for duodenal cancers because it might be due to development of duodenal endoscopic examination. • For early cancers, duodenal resection preserved surrounding organs such as a pancreas can be indicated, otherwise pancreaticoduodenectomy is necessary for advanced stage duodenal cancer located up to 3rd portion of duodenum. • Patient prognosis can be expected by the novel adjuvant chemotherapy after curative duodenectomy. [ABSTRACT FROM AUTHOR]

Tachycardia-induced cardiomyopathy is an unusual cardiac disease that is life-threatening if tachycardia is not controlled. We report a 12-year-old boy who suffered from ectopic left atrial tachyarrhythmia that was refractory to medications and caused tachycardia-induced cardiomyopathy with severe heart failure. The patient required a left ventricular assist device (ABIOMED BVS5000 [ABIOMED Inc, Danvers, MA]) as a bridge to recovery. Tachycardia was finally controlled with flecainide while the patient was on left ventricular assist device support. The device was successfully explanted after 28 days of support. The temporary use of a left ventricular assist device was necessary to maintain a good hemodynamic status during the treatment of pharmacological refractory tachycardia, and it allowed a successful bridge to recovery. [Copyright &y& Elsevier]

Abstract: Although mutations of autoimmune regulator (AIRE) gene are responsible for autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), presenting a wide spectrum of many characteristic and non-characteristic clinical features, some patients lack AIRE gene mutations. Therefore, something other than a mutation, such as dysregulation of AIRE gene, may be a causal factor for APECED or its related diseases. However, regulatory mechanisms for AIRE gene expression and/or translation have still remained elusive. We found that IL-2-stimulated CD4+ T (IL-2T) cells showed a high expression of AIRE gene, but very low AIRE protein production, while Epstein–Barr virus-transformed B (EBV-B) cells express both AIRE gene and AIRE protein. By using microarray analysis, we could identify miR-220b as a possible regulatory mechanism for AIRE gene translation in IL-2T cells. Here we report that miR-220b significantly reduced the expression of AIRE protein in AIRE gene with 3′UTR region transfected 293T cells, whereas no alteration of AIRE protein production was observed in the open reading frame of AIRE gene alone transfected cells. In addition, anti-miR-220b reversed the inhibitory function of miR-220b for the expression of AIRE protein in AIRE gene with 3′UTR region transfected cells. Moreover, when AIRE gene transfected cells with mutated 3′UTR were transfected with miR-220b, no reduction of AIRE protein production was observed. Taken together, it was concluded that miR-220b inhibited the AIRE gene translation through the 3′UTR region of AIRE gene, indicating that miR-220b could serve as a regulator for human AIRE gene translation. [Copyright &y& Elsevier]

Background: the role of endovascular brachytherapy in restenosis prevention is well documented. Dose is usually prescribed at a fixed distance from the source axis by angiographic quantification of vessel diameter. Recently, intravascular ultrasound (IVUS) was introduced in dose prescription, allowing a better evaluation of the vessel anatomy. This study retrospectively explores the difference between prescription following angiographic vessel sizing and delivered dose calculated with IVUS. Methods and results: Seventeen lesions were studied with IVUS, identifying on irradiated segment, three sections on which measuring minimal and maximal distance from the centre of IVUS catheter to the adventitia; using dedicated software, corresponding doses were calculated. The dose ranged widely, with maximal and minimal values of 71.6 and 4.9 Gy; furthermore, heterogeneity in dose among different sections was observed. In the central section, the maximal dose was 206% of the one prescribed with the QCA model at 2 mm from the source axis, while the minimal dose was 96%. In proximal and distal sections, respective values were 182, 45, 243, and 122%. Conclusions: Our analysis confirmed the dose inhomogeneity delivered with an angiographic fixed-dose prescription strategy. A dose variation was found along the irradiated segment due to the differences in vessel thickness. IVUS emerged as an important tool in endovascular brachytherapy, especially for irregular-shaped vessels. [Copyright &y& Elsevier]

Intimal hyperplasia after balloon dilatation may be related to the severity of vascular injury, and cutting balloon angioplasty (CBA) may reduce vascular injury. The present study investigated the mechanism of vasodilation by CBA. Intravascular ultrasound examination was performed before and after intervention in 40 lesions treated with CBA and in 25 lesions treated with conventional balloon angioplasty. Intravascular ultrasound measurements included the vessel area, luminal area, and plaque area. Vessel expansion was evaluated as the ratio of the postprocedural vessel area to that before intervention. The vessel area was 13.9 ± 3.2 and 14.8 ± 3.2 mm2 after CBA versus conventional angioplasty, respectively, whereas the luminal area was 5.5 ± 1.2 versus 5.7 ± 1.2 mm2 and the plaque area was 8.5 ± 2.7 versus 9.1 ± 2.2 mm2, respectively. The vessel area was smaller and the plaque area significantly smaller after CBA. Vessel expansion accounted for 45% of luminal enlargement, and plaque compression or shift accounted for 55% after CBA. After conventional angioplasty, vessel expansion accounted for 67%, and plaque compression or shift for 33% of luminal enlargement. The vessel expansion ratio was significantly smaller after CBA than after conventional angioplasty (1.05 vs 1.22, p <0.05). These findings suggest that the predominant mechanism of dilatation after CBA is plaque compression or shift rather than vessel expansion, unlike conventional angioplasty. [Copyright &y& Elsevier]

The functional significance of coronary artery stenoses of intermediate severity is important in determining strategy in patient care. Intravascular ultrasound (IVUS) is often used to evaluate coronary stenosis severity. However, at present, few data are available about the role IVUS in the assessment of functional significance of intermediate lesions. Myocardial fractional flow reserve (FFR) <0.75 is a reliable index of a functionally severe coronary stenosis. In 53 lesions we assessed (1) by pressure wire: FFR (index of functional significance), and (2) by IVUS: minimal lumen cross-sectional area (MLA, square millimeters), minimal lumen diameter (MLD, millimeters), lesion length (millimeters), and percent area stenosis at the lesion site. By regression analysis, percent area stenosis and lesion length had a significant inverse correlation with FFR (r = -0.58, p <0.001, r = -0.41, p <0.004, respectively). MLD and MLA showed a significant positive relation with FFR (r = 0.51, p <0.001, r = 0.41, p <0.004, respectively). By using a receiver operating characteristic (ROC) curve, we identified a percent area stenosis > 70% (sensitivity 100%, specificity 68%), a MLD < or = 1.8 mm (sensitivity 100%, specificity 66%), a MLA < or =4.0 mm2 (sensitivity 92%, specificity 56%), and a lesion length of >10 mm (sensitivity 41%, specificity 80%) to be the best cut-off values to fit with a FFR <0.75. The combined evaluation of both percent area stenosis and MLD made the IVUS examination more specific (sensitivity 100%, specificity 76%). In 53 intermediate coronary lesions found by angiography, IVUS area stenosis >70%, MLD < or =1.8 mm, MLA < or =4.0 mm2, and lesion length > 10 mm reliably identified functionally critical intermediate coronary stenoses. [ABSTRACT FROM AUTHOR]