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Aim: During surgery for an aortic arch aneurysm, aortic plaque in the descending aorta should be evaluated, but there are currently no suitable biomarkers for it. Surgeons should be especially aware of cerebral embolism from femoral perfusion and of peripheral embolism from stent graft deployment. Cystatin C is a known useful marker of renal dysfunction with a role as a biomarker for severity of coronary artery disease. In the absence of a suitable biomarker for aortic plaque in the descending aorta, we examine cystatin C as a candidate. Methods: In all, 75 patients who underwent surgery for an aortic arch aneurysm were enrolled. They were divided into two groups, depending on whether they had chronic kidney disease or not. The serum cystatin C value and creatinine value were evaluated preoperatively. The aortic plaque volume ratio and components in the descending aorta were calculated from preoperative enhanced computed tomography. Results: The soft plaque volume ratio was higher in patients with chronic kidney disease than in patients without it. Cystatin C positively correlated with the total aortic plaque volume ratio in all cases, and it positively correlated with the soft plaque volume ratio in both groups. Creatinine had no correlation with any type of plaque volume ratio in either group. In patients without chronic kidney disease, the soft plaque volume ratio was higher in patients with higher cystatin C levels than in patients with normal levels. Conclusion: The preoperative serum cystatin C level could be a biomarker of aortic plaque in the descending aorta in patients with an aortic arch aneurysm.

Tumours or tumour-like lesions around the aortic valve are relatively rare and are difficult to diagnose. We report an interesting case of calcified thrombi in the Valsalva sinuses and coronary cusps that mimicked an aortic valve tumour. A 68-year-old man presented with a 20-mm calcified mass in the non-coronary and left-coronary cusps extending to their corresponding Valsalva sinuses, which was detected by echocardiography and contrast-enhanced computed tomography. The lesions were resected to establish the diagnosis and prevent systemic embolization. Intraoperative and histopathological examination revealed an atrophied non-coronary leaflet and calcified atherosclerotic lesions of the Valsalva sinuses and contiguous parts of the cusps, with ulceration and fibrin thrombi. The lesions were resected and aortic valve replacement was performed to avoid aortic valve dysfunction. The patient’s atrial fibrillation was controlled, and anticoagulants were discontinued 3 months postoperatively. Surgery to establish the diagnosis and to prevent systemic thromboembolism was thought to be reasonable, even in the absence of valvular dysfunction.

Adventitial cystic disease of the femoral vein is an extremely rare condition; therefore, diagnosis, treatments, surgical approaches and long-term prognosis are not well defined. We report the case of a 67-year-old man with femoral vein adventitial cystic disease complicated with deep vein thrombosis. He presented with right leg oedema. Ultrasound, computed tomography and magnetic resonance imaging revealed a mass in the femoral vein, and deep vein thrombosis was not detected at the time. However, venous return disorder worsened due to the mass causing a deep vein thrombosis in the femoral vein, and anticoagulation therapy with edoxaban was administered. Subsequently, deep vein thrombosis in the femoral vein disappeared, but remained in the lower calf. The mass and femoral vein were completely resected and reconstructed with an expanded polytetrafluoroethylene graft. No recurrence was observed over 3 years and 3 months.

Patients with left ventricular hypertrophy (LVH) have reportedly higher than normal mortality and incidences of cardiovascular events. Coronary microvascular pathophysiology also appears to differ from other populations. Such coronary microcirculation dysfunctions are considered strong causes of cardiac events. We compare the functional improvement of myocardial ischemia between LVH patients and other patients after successful coronary artery bypass surgery (CABG) using coronary flow velocity reserve (CFVR) by transthoracic echo cardiography. Patients who underwent isolated coronary artery bypass surgery, including left anterior descending artery (LAD) revascularization via "in situ" internal thoracic artery (ITA) between June 2008 and July 2017 (n = 155), were retrospectively reviewed. ITA grafts were patent in postoperative graft evaluation in all patients. CFVR was evaluated pre- and postoperatively, and data were compared between patients with severe LVH group and those without (non-LVH group). Preoperative mean CFVR was 1.77 ± 0.75 in LVH group and 1.91 ± 0.63 in non-LVH group (P = 0.188). After the operation, ITA to LAD graft patency was confirmed in all patients. Postoperative CFVR was 2.23 ± 0.70 in LVH group and 2.85 ± 0.71 in non-LVH group, respectively (P = 0.002). Significant difference was observed between the 2 groups. CFVR values improved after ITA to LAD bypass grafting in both LVH and non-LVH groups, but postoperative CFVR was significantly lower in patients with severe LVH than in patients without. Myocardial ischemia may exist in patients with LVH, despite patent graft, due to microvascular dysfunction. Comprehensive treatment, including long-term oral medication to improve microvascular dysfunction, is necessary for patients with LVH.

We describe the repair of an acute aorto-pulmonary artery fistula in a 82-year-old patient with a ruptured aortic arch aneurysm using a frozen elephant trunk technique.

Cardiac surgery in patients with essential thrombocythemia carries the risks of both thrombotic events and a bleeding tendency. We report the case of a 75-year-old man with essential thrombocythemia who underwent successful surgical aortic valve replacement after his platelet count was controlled with plateletpheresis 3 times before surgery.

A 19-year-old man with Down syndrome had congenital mitral regurgitation. He had slight mental retardation and difficulty in performing independent oral drug administration. We planned mitral valve plasty to avoid postoperative anticoagulant therapy. The mitral valve lesions were complicated. A prolapsed anterior mitral leaflet, shortened posterior leaflet, abnormal cleft, abnormal papillary muscle, and enlarged annulus were observed. Successful mitral valve plasty was performed using several techniques. The postoperative course was uneventful, and no significant mitral regurgitation was found.

OBJECTIVES To avoid cerebral infarction for aortic arch aneurysm and malperfusion for acute aortic dissection, the site of cannulation during total arch replacement remains important. Recently, we have used bilateral axillary artery perfusion in total arch replacement and in acute aortic dissection. Herein, we report the surgical outcomes. METHODS Seventy-eight patients with aortic arch aneurysm and 45 patients with acute aortic dissection were enrolled in this study. During surgery, translocation of the total arch was performed on 67 patients using a ‘frozen elephant trunk technique’. RESULTS In patients with aortic arch aneurysm, there was no postoperative cerebral infarction. New postoperative cerebral infarction was observed in only one patient who underwent acute aortic dissection. Two patients who had aortic arch aneurysm and 2 patients who had acute aortic dissection died at the hospital. Complications related to bilateral axillary perfusion were not observed. CONCLUSIONS The routine use of bilateral axillary artery perfusion in total arch replacement for aortic arch aneurysm to avoid cerebral infarction has the potential to be a useful procedure. It can facilitate the frozen elephant trunk procedure in acute aortic dissection.

BACKGROUND In patients with end-stage renal disease requiring hemodialysis (HD patients), myocardial ischemia after coronary artery disease is a major cause of mortality. Coronary pathophysiology, namely myocardial microvascular dysfunction, appears to differ from patients not requiring HD (non-HD patients). OBJECTIVES We compared functional improvement of myocardial ischemia after coronary artery bypass surgery (CABG) between HD and non-HD patients by transthoracic coronary flow velocity reserve (CFVR). METHODS We retrospectively reviewed isolated CABG patients from between 2008 and 2017. Finally, 161 patients were enrolled; each underwent pre- and postoperative CFVR assessment, and left anterior descending (LAD) artery revascularization with "in-situ" internal mammary artery (IMA). Graft patency was confirmed, and after successful CABG, postoperative CFVR improvement between the two groups was compared. RESULTS Preoperative CFVR value in group H was 1.81 ± 0.52, group N was 1.93 ± 0.66. There was no significant difference between the groups. IMA to LAD grafts were patent in postoperative evaluation in all patients. Postoperative CFVR in group H was 2.48 ± 0.72 and group N was 2.83 ± 0.73 (P = .042). Significant difference was observed. CONCLUSION In both groups, CFVR values improved after successful CABG, but postoperative CFVR values were significant different. In younger populations CFVR values are generally higher. Our HD group was significantly younger than the non-HD group, but CFVR values were postoperatively significantly lower. CFVR values are reportedly affected by both epicardial and microcoronary circulation. In this study population, as all grafts to the LAD were patent, the lower CFVR value in the HD group was considered to have resulted in microvascular disorders.

Background Pressure guidewire pullback recording can differentiate between functional focal and diffuse disease types in coronary artery disease. The aim of this study was to compare the outcome of coronary artery bypass graft (CABG) patency between patients with functional focal versus diffuse disease types in recipient coronary arteries. Methods and results We investigated 89 patients who underwent pressure guidewire pullback in the left anterior descending (LAD) artery before CABG using internal mammary artery (IMA). Based on the pressure guidewire pullback data, the LAD lesions were classified into functional focal disease (abrupt pressure step-up; n=58) or functional diffuse disease (gradual pressure increase; n=31). Follow-up computed tomography (CT) angiography was conducted within 1year after CABG to assess the bypass graft patency. Pre CABG, LAD angiographic percent diameter stenosis (57±10% vs. 54±12%, p=0.228) and fractional flow reserve (FFR) (0.68±0.07 vs. 0.69±0.07, p=0.244) were not different between the functional focal and diffuse disease groups. The CABG procedure characteristics were similarly comparable between the two groups. In the follow-up CT angiography after CABG, occlusion or string sign of the IMA graft to LAD was more frequently observed in the functional diffuse disease group than in the functional focal disease group (26% vs. 7%, p=0.021). Conclusion In CABG, functional diffuse disease in the recipient coronary artery was associated with an increased risk of the graft failure in comparison with functional focal disease.

The study identified seasonal habitat use by endangered adult Sakhalin taimen, Hucho perryi and the environmental characteristics of their habitats (water depth, amount of riparian forest, and meandering sinuosity). Fifteen adult H. perryi with acoustic tags were tracked by towing an acoustic receiver with a canoe in the Bekanbeushi River system in eastern Hokkaido Island, Japan during each month from late April to late November 2008. Individuals mainly used midstream (shallower than downstream) habitats in all seasons. These locations were generally characterized by relatively dense riparian forests and high sinuosity, indicating the presence of pools. In spring, individuals used habitats with less riparian forest cover compared to mean value of the river channel. From spring to autumn, adult H. perryi selected limnologically complex habitats with meandering channels. From summer to autumn, individuals selected habitats with more riparian forest cover. The inverse relationship between H. perryi detection and riparian forest area in spring was a result of seasonal defoliation in deciduous riparian forests.

A flow-mediated endothelium-dependent vasodilation and endothelium-independent nitroglycerin-induced vasodilation were carried out in 70 patients and 15 age-matched adults without any atherosclerotic risk factors to clarify vascular responsiveness in patients with atherosclerotic peripheral vascular disease. The percent change in flow-mediated vasodilation was significantly lower in patients than in controls (5.4 ± 0.7% vs 12.8 ± 2.2%, P < .001). Moreover, the percent change in nitroglycerin-induced vasodilation measured after sublingual administration of nitroglycerin was lower in patients than in controls (5.8 ± 0.6% vs 10.2 ± 1.5%, P < .01). On multiple regression analysis, none of the determinant factors showed a significant correlation with flow-mediated vasodilation. In contrast, Fontaine classification was found to be a significant predictor for nitroglycerin-induced vasodilation ( r = −0.307, P < .05). There is a significant positive correlation between nitroglycerin-induced vasodilation and ankle-brachial pressure index in the patients. The data showed that vasoditation function were markedly impaired in end-stage patients with peripheral vascular disease.

Objective To evaluate the relationship between preoperative severity of coronary stenosis occurring with fractional flow reserve (FFR), and the intraoperative bypass graft flow pattern. Methods In all, 72 patients were enrolled in this retrospective study. The FFR value of the left anterior descending artery was evaluated, and data on "in situ" bypass grafting from the internal thoracic artery to the left anterior descending artery were assessed. Patients were divided into 3 groups according to preoperative FFR values (Group S: FFR Results In groups S, M, and N, respectively, mean graft flow was 24.7 ± 10.6 mL/minute, 19.2 ± 14.0 mL/minute, and 16.0 ± 9.7 mLmL/minute; pulsatility index was 2.35 ± 0.6, 3.02 ± 1.1, and 5.51 ± 8.20; and number of patients with systolic reverse flow was 3 (6.8%), 5 (35.7%), and 4 (28.6%). Significant differences were observed in graft flow ( P = .009), pulsatility index ( P = .038), and proportion of systolic reverse flow ( P = .023) among the 3 groups. In all patients, graft patency was confirmed with intraoperative fluorescence imaging; postoperative graft patency was confirmed with multislice computed tomography or coronary angiography in 69 patients (follow-up interval: 213 days). Early graft failure occurred in 1 patient. Conclusions As coronary stenosis severity increased, graft flow increased, pulsatility index decreased, and proportion of patients with systolic reverse flow increased. In mild coronary artery stenosis, the chance of flow competition between the native coronary artery and the bypass graft increased.

Although the outcomes of total arch replacement have been improving, the prevention of cerebral infarction is still an important consideration in aortic arch surgery. Herein, we reviewed our experience with total arch replacement using antegrade selective cerebral perfusion under right axillary artery perfusion. Between January 2002 and March 2013, total arch replacement was performed for 125 patients including 31 patients with acute aortic dissection. An 8 mm polyester grafts was sutured to the axillary artery through the right subclavicular incision and was connected to cardiopulmonary bypass circuit. Antegrade selective cerebral perfusion under hypothermic circulatory arrest was initiated using right axillary artery perfusion. Postoperative cerebral infarction occurred in 5.6% of patients. Hospital mortality rate was 3.2%. The 5-year rate of freedom from aortic event was 83%. The 5-year survival rate was 75%. We consider that right axillary artery perfusion is advantageous for preventing cerebral infarction in total arch replacement.

A 41-year-old man was urgently admitted with sudden onset of chest pain. Emergency coronary angiography revealed a large aneurysm of the sinus of Valsalva and reduced blood flow in the left coronary artery. A modified Bentall operation and coronary artery bypass were performed successfully. A large sinus of Valsalva aneurysm should be regarded as a critical problem that could cause coronary insufficiency.

Acoustic telemetry and microchemical analysis of otolith strontium–calcium ratios were used to evaluate how exotic brown trout Salmo trutta have responded to Japanese riverine environments of south-western Hokkaido by observing their migratory patterns. The existence of anadromous S. trutta was also verified. Most S. trutta caught in rivers for otolith analysis were freshwater residents (95·6%), whereas those caught in the sea were mainly smolts (91·3%), which had just migrated from rivers during spring. Anadromous S. trutta (n = 6) were captured in rivers and in the sea, confirming the existence of mature pre- and post-spawning fish. According to telemetry results, both mature and immature S. trutta used the river in winter, and their estimated sea-run timings showed individual differences. Through the combination of these two methods, migratory patterns on various spatio-temporal scales were observed. This first documentation of the presence of both male and female anadromous S. trutta in the same region within Japan indicated the risk of further colonization of exotic S. trutta via oceanic migration.

A 75-year-old man with gastric cancer underwent preoperative cardiac examination by echocardiography, and an unruptured extracardiac aneurysm was detected in the right sinus of Valsalva. Coronary angiography by multidetector computed tomography demonstrated a single left coronary artery. Patch closure of the orifice of the aneurysm of the right sinus of Valsalva was successfully performed for this extremely rare combination.

Objective: Operative stress of cardiovascular surgery can alter the blood levels of various physiologically active substances (e.g., cytokines, growth factors), and thus potentially affect cancer cell proliferation. How the combination of changes in blood levels of these substances affects cancer cells has not been adequately addressed. We investigated the stimulatory capacity on cancer cells of serum from patients after cardiovascular surgery, using a novel in vitro assay method. Methods: The subjects were 22 patients undergoing cardiovascular surgery, consisting of 11 off-pump and 11 on-pump procedures. Blood was sampled from each subject immediately before surgery, immediately after surgery, and after transfer to the intensive care unit. Human lung cancer cells were exposed to the serum of each blood sample from each patient, and an MTT assay was conducted to evaluate cell proliferation. Results: Serum samples of all patients showed an inhibitory effect for lung cancer cell proliferation. This inhibitory effect was lower in postoperative serum compared with serum samples before surgery. As a result, lung cancer cell proliferation was better with postoperative serum samples than preoperative serum samples. The proliferation rate after surgery, when it was compared with preoperative serum, was significantly higher in patients with on-pump procedures than in patients with off-pump procedures. Conclusion: The results of this study suggest that the operative stress of cardiovascular surgery induces changes in serum to make it less inhibitory for the cancer cell proliferation. This phenomenon is greater in patients with extracorporeal circulation.

We report an extremely rare case of pulmonary artery dissection caused by an abrupt rupture of an aortic arch aneurysm into the pulmonary artery. An asymptomatic 80-year-old man was admitted to our hospital for elective surgical repair of aortic arch aneurysm. After admission, sudden onset of hoarseness and dyspnea developed. Echocardiography demonstrated an intimal flap in the pulmonary artery and abnormal shunt flow from aortic arch aneurysm into the pulmonary artery. At surgery, the pulmonary artery dissection involved the main pulmonary artery and both major branches. Total arch replacement and pulmonary artery reconstruction were successfully performed.

To improve the response to chemotherapy for non-small cell lung cancer (NSCLC), effective drugs should be selected for each patient. In 1994 we introduced histoculture drug response assay (HDRA) for NSCLC patients. For clinical N2 patients, biopsy of mediastinal lymph node is performed both for histological diagnosis and for HDRA. Induction concurrent chemoradiotherapy is then performed using HDRA positive chemotherapy agents. We have treated three patients with this strategy. HDRA could be performed using mediastinal lymph node biopsy specimens. Tumor reduction rates of these patients were 80.4%, 85.3%, and 57.1%. Their histological responses were Ef.3, Ef.2, and Ef.1b, respectively. Complete resection was done in all patients. This strategy appeared to be useful in NSCLC patients with mediastinal lymph node metastasis.

The Ionescu-Shiley pericardial valve (Shiley, Inc, Irvine, CA, USA) is a first generation bioprosthesis made from bovine pericardium. Despite its excellent hemodynamic performance, use of this prosthesis ceased because it had an unacceptably high rate of early structural deteriorations, especially in the era of the standard profile valve. We experienced a rare case of very long durability of an Ionescu-Shiley standard profile (ISSP) bioprosthesis.

A 78-year-old man who underwent coronary artery bypass surgery and mesenteric artery bypass surgery 6 months previously presented with a groin swelling. Occlusion of the celiac artery and severe stenosis of the superior and inferior mesenteric arteries had been detected before the coronary bypass. Two days after the coronary bypass, sudden bowel ischemia occurred. The visceral organs appeared to be free of necrotic changes, but the bowel was pale. As the patient needed immediate reperfusion of the bowel, we selected an artificial graft and chose to perform bypass grafting from the femoral artery to the superior mesenteric artery through the intraperitoneal free space. Therefore, emergency bypass surgery from the femoral artery to the superior mesenteric artery using a ringed expanded polytetrafluoroethylene graft (ePTFE) was performed (A/Cover). When the patient was admitted to our hospital 6 months after the operation, his left groin was swollen, and he had a low-grade fever. His appetite was very good, and there were no symptoms of panperitonitis. Emergency computed tomography revealed the occlusion of the ePTFE graft, air in the graft, and the migration of the graft into the small intestine (B and C) Cultures from the left groin grew Torulopsis glabrata and Escherichia coli, but blood cultures were negative. An urgent graft excision was performed. The graft was severely adhered to the sigmoid colon, and the body of the graft had perforated the small intestine (D). We removed the graft from the small intestine and found that it was filled with pus. After graft excision, the defects at the anastomotic site were patched with saphenous vein. Cultures of the artificial graft grew E. coli and Enterococcus faecalis. Antibiotics were administered for 2 weeks, and the infection was controlled well. This is a very rare case of the migration of an artificial graft into the small intestine. This case shows that bypass grafting from the femoral artery to the mesenteric artery through the intraperitoneal free space may cause the adhesion of the graft to the bowel and induce the perforation of the small intestine, and grafts should ideally be fixed to the retropertioneum.

l I l t f T W l e p l e v t a i t t A 78-year-old man was admitted to our hospital with angina pectoris and multiple coronary risk factors. oronary angiography revealed severe coronary lesions nd an angiography of the left internal thoracic artery LITA) showed collateral arteries leading from the LITA o the visceral arteries (Fig 1). Evaluation of these collatrals using multi-slice computed tomography revealed otal occlusion of the celiac trunk (CT), as well as severe tenosis of the superior mesenteric artery (SMA), and the nferior mesenteric artery (IMA). Abnormal collateral irculation from the LITA to the CT through the muscuophrenic artery (MPA), left inferior phrenic artery LIPA), and left gastric artery (LGA) had developed along ith other collaterals leading from the right internal horacic artery (RITA) to the hepatic artery through the PA and the right inferior phrenic artery (RIPA) (Fig 2). ecause the symptoms of abdominal angina were absent, e performed isolated off-pump coronary artery bypass urgery with a radial graft to the left anterior descending oronary artery and saphenous vein grafts to the left ircumflex artery and right coronary artery. Two days