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A 69-year-old man developed sudden-onset chest and back pain and was brought to our hospital. Enhanced computed tomography (CT) revealed acute Stanford type B aortic dissection extending from the distal aortic arch to a 72 mm abdominal aortic aneurysm( AAA). The acute phase was managed by antihypertensive therapy, and the patient was followed up. Twenty days after the onset of aortic dissection, entry closure of aortic dissection by thoracic endovascular aortic repair and abdominal aorta replacement were performed simultaneously. Aorta remodeling was confirmed by postoperative CT, and the patient's postoperative course was uneventful. In the treatment of patients with acute aortic dissection and AAA, surgical intervention timing and strategy must be considered carefully.

A 65-year-old man was referred to our hospital because of an abnormal shadow on a chest radiogram. Swelling of the face and upper limbs were noted. Enhanced computed tomography showed a 62×101 mm mass in the anterior mediastinum with invasion to the superior vena cava (SVC) and the right upper lobe of the lung. Surgical resection through a sternotomy was performed. The mediastinal tumor was resected along with the left brachiocephalic vein, the part of SVC wall and the partial right upper lobe of the lung with a clamp on the proximal SVC, followed by a left brachiocephalic vein reconstruction. There has been no evidence of recurrence after 1 year. This procedure may be an efficacious technical option in case of anterior mediastinal invasive tumor.

We present a rare case of intimal sarcoma arising from the common iliac artery in an 82-year-old man who presented with intermittent claudication. He had undergone endovascular therapy with self-expanding stents to both iliac arteries that had occluded soon after placement. After salvage bypass grafting, a diagnosis of intimal sarcoma with angiosarcoma phenotype from the iliac artery was made. Further bypass graft surgery relieved symptoms temporarily. However, the tumor progressed and the left limb became ischemic. The chemotherapy of eribulin did not prevent tumor progression. The patient died of the disease 20 months after the first surgery. J. Med. Invest. 66 : 205-208, February, 2019.

Objectives: To determine the efficacy and the optimal timing of thoracic endovascular aortic repair (TEVAR) for closing the primary entry in uncomplicated patients with chronic type B aortic dissection and a patent false lumen (FL). Methods: Thirteen patients underwent TEVAR for aortic dissection between 2008 and 2012. These patients had chronic dissection with a patent FL and expansion of the aorta. Early TEVAR was performed for five patients within 1–7 months from the index dissection (TEVAR-EC group) and delayed TEVAR was performed for eight patients within 1–16 years (TEVAR-DC group). Changes in the diameters and volumes of the true lumen (TL) and FL and the aortic remodeling were assessed by multidetector computed tomography for 3 years after TEVAR. Results: The reduction rate of FL in the thoracic aorta was notably higher in the TEVAR-EC group than in the TEVAR-DC group regardless of the presence or absence of distal retrograde flow. There was a significant TL expansion despite different timings of TEVAR. Conclusions: Early TEVAR resulted in good prognosis and preferable aortic remodeling in uncomplicated patients with chronic type B aortic dissection and a patent FL, and we recommend early TEVAR within seven months after the index dissection.

The endovascular approach to aortic aneurysm repair is widely spreading as an alternative to open repair. However infectious complications may be devastating. We described the experiences with infected aortic endografts and reviewed treatment and outcomes.Eight patients were treated due to infected aortic endografts between June 2008 and March 2014. Seven males and 1 female with median age of 66 years( range, 38-84years) had 5 infected thoracic endovascular aortic repairs (EVARs) [5/142:3.5%] and 3 endovascular aortic repairs (EVARs)[3/387:0.8%]. Median time from repair to presentation was 12 months (range, 2-27 months). As the factors associated with infection, hemodialysis due to chronic kidney disease in 1, surgical treatment for the huge atheroma in 1, dental treatment in 2, treatment for infected aneurysm in 1, urinary tract infection after surgery for prostate in 1, aortoenteric fistula after TEVAR in 2 were considered.Five patients were treated with endograft explantation. The surgical mortality was 40% (2/5), during a follow-up, one more patient died with intracranial hemorrhage. The remaining 3 patients who were considered too high risk to remove the infectious endografts were treated conservatively with antibiotics. In 2 of them 1 died of respiratory failure, and multiple organ failure in 1.Infection of the endograft is a rare but devastating complication after endovascular repair of aortic aneurysms. Surgical removal of the infected prosthesis is accompanied with higher mortality, but antibiotics therapy cannot eradicate or cure the infection. In all cases, the factors associated with infection were calculated, and degenerative or infectious thrombi around the endovascular stent grafts were noted. Therefore, we consider that prophylactic antibiotic treatment may be necessary to prevent the bacteremia in the case of other surgical therapy or dental treatment.

Objective: We examined the influence of shunt size on regulation of the pulmonary blood flow in a canine model of a univentricular heart because specific guidelines regarding suitable shunt size in the Norwood operation remain undetermined. Methods: Beagle dogs (n = 8) 3 to 7 months old and weighing 3.0 to 5.0 kg were used. Atrial septectomy and patch closure of the tricuspid valve were performed, and a systemic-pulmonary arterial shunt was created by interposing a 3.5- or 4.0-mm graft between the right subclavian artery and main pulmonary artery. After cardiopulmonary bypass, hemodynamic variables including pulmonary and systemic blood flow were measured consecutively according to physiologically respiratory manipulations. The ratio of shunt size to body weight ranged from 0.80 to 1.33 mm/kg (1.08 ± 0.16 mm/kg). Results: Each dog with a ratio of shunt size to body weight of 0.8 to 1.1 showed significant negative correlation between the pulmonary/systemic blood flow ratio and arterial Pco 2 , but those with a ratio of shunt size to body weight of 1.1 to 1.4 did not. Consequently each dog with a ratio of shunt size to body weight of 0.8 to 1.0 got adequate systemic flow, whereas a ratio of 1.0 to 1.4 resulted in inadequate systemic flow and acidic status. Similar phenomena were shown with the grouped data on relationship between the pulmonary/systemic blood flow ratio and inspired oxygen fraction. Conclusions: These findings imply that when the ratio of shunt size to body weight is 0.8 to 1.1, the pulmonary/systemic blood flow ratio is controllable by physiologic respiratory manipulations. Larger shunts make pulmonary blood flow excessive and uncontrollable. We recommend that a ratio of shunt size to body weight of 0.9 to 1.0 be considered a useful index for suitable systemic-pulmonary arterial shunt in the Norwood operation. J Thorac Cardiovasc Surg 2003;125:71-8

We experienced a case of a 38-year-old woman with a persistent cough, 24 years after repair of absent pulmonary valve syndrome with anomalous origin of the left pulmonary artery. The right pulmonary artery was massively dilated, thus it caused the compression of the bronchi, which was thought to result in her respiratory symptom. This dilatation of the right pulmonary artery seemed to have progressed because of the following two reasons. The first is the pulmonary hypertension caused by the late reconstruction of the left pulmonary artery. The second is residual pulmonary stenosis and regurgitation after the initial operation without a pulmonary valve insertion. We performed a reoperation consisting of reconstruction of the right ventricular outflow tract using a valved conduit and plication of the right pulmonary artery. Her postoperative course has been without any complications and satisfactory for the past 2 years.

治療に難渋した人工血管感染5症例について検討した. 年齢は57～81歳, 初回手術時の基礎疾患は Leriche 症候群1例を含む閉塞性動脈硬化症3例, 悪性腫瘍の動脈浸潤2例であった. 人工血管感染部位は鼠蹊部3例, 膝上部1例, 腹部1例で, うち4例の起炎菌は Staph. aureus (MRSA3例) であった. 感染原因となった人工血管の手術から感染発現までの期間は, 腹膜炎症例は10日と短く, 末梢側の感染では2か月～14年と長かった. 腹膜炎例を除いた症例での感染巣のドレナージ, 洗浄等の保存的治療期間は40～64 (平均50) 日であった. 手術はグラフトの感染部位のみの除去またはグラフト全部を摘出し, 新たな血行再建術を施行した. 感染グラフトはPTFE4例, Woven-Dacron 1例で, 再手術にも同様のグラフトを用いた. 感染部を避けるため, 閉鎖孔経由など3例で別経路を用いた. 感染人工血管の全摘出が困難な症例では, 感染巣部のみの人工血管摘除と健常な周囲組織での再建術を行い良好な結果を得た. 手術成績は全例生存, 敗血症や下肢切断等の重篤な合併症は認めなかった. 再手術から現在までの8か月～8年間, 全例開存し再感染も認めていない.

Transcranial Doppler sonography is frequently used to monitor cerebral blood flow velocities during open heart surgery. There was little information about Doppler findings in patients with congenital heart diseases and valvular heart diseases.This study included 12 women and six men, with a mean age of 40.6 years. Two patients had ventricular septal defect, four were diagnosed as having atrial septal defect, and one had both defects. Eleven patients underwent surgical replacement of heart valves. Two underwent aortic valve replacements and two underwent surgery on both the aortic and mitral valves. In seven patients, the mitral valve was replaced because of mitral regurgitation. The maximum, mean, and minimum flow velocities of the left middle cerebral artery (MCA) were measured intraoperatively before and after replacement. In the patients with aortic insufficiency and ventricular septal defect, the mean and diastolic flow velocities were markedly reduced on Doppler recordings before valvular replacement. In the patients with aortic insufficiency, a bisferious pulse was found on the Doppler spectra. In contrast, in the patients with mitral regurgitation and atrial septal defect, the Doppler waveforms showed normal findings preoperatively. In the patients with raised intracranial pressure, a high value of PI and low diastolic flow velocities were found on the TCD spectra. The same findings were sometimes seen in the patients with aortic insufficiency or ventricular septal defect. In patients with mitral insufficiency or atrial septal defect, the Doppler spectra showed no change on the TCD records postoperatively. Spiky contours were detected by Doppler in the patients with valvular heart disease secondary to subacute endocarditis.It is concluded that TCD could provide an approximation of changes in cerebral blood flow velocity in patients with valvular heart disease and ventricular septal defect.

It has been hypothesized that epicardial fat, a local visceral fat depot with close proximity to coronary arteries, may serve as a source of inflammatory cytokines and cells in coronary atherosclerotic lesions. Here, we characterized infiltration of inflammatory cells and expression of adipocytokines in epicardial adipose tissue in patients with and without coronary artery disease (CAD). Pare samples were obtained from epicardial and subcutaneous adipose tissue during elective cardiac surgery (CAD, n = 8; non-CAD, n = 9). Inflammatory cell infiltration was investigated by immunohistochemical staining using antibodies against CD3, CD4, CD8 and CD68. Expression of adipocytokines was evaluated by real-time quantitative reverse transcription-polymerase chain reaction. Infiltration of macrophages and CD8-positive T cells in the epicardial adipose tissue in the CAD group was greater than that in the non-CAD group. In contrast, there was no significant difference between the two groups in the number of inflammatory cells in subcutaneous adipose tissue. No statistical difference could be found between the CAD group and the non-CAD group in the expression levels of adiponectin and inflammatory cytokines in epicardial adipose tissue. Our findings suggest that inflammatory cell infiltration is enhanced in epicardial adipose tissue, but not in subcutaneous fat, in patients with coronary artery disease. Chronic inflammation in epicardial fat may influence the pathogenesis of coronary atherosclerosis.

No consensus exists on the etiology and diagnostic criteria for Dieulafoy's ulcer. To clarify the characteristics of this disease, clinical and pathological evaluation was made on 13 cases treated surgically in Tokushima Municipal Hospital. It was most frequently found in the upper gastric body (6 patients), while multiple ulcers were found in six cases. The depth of ulceration was UL-II in seven and UL-III in six cases. The ulcerations measured from 3×5 mm to 10×25 mm, with the diameter of the exposed vessels ranging from 1.0 mm to 2.5 mm.In all cases examined, the exposed vessels run without changing their diameters even after penetrating through the muscular layers, but ruptured after reaching the submucosa. None, however, showed arteritis or aneurysm, and only mild arteriosclerosis was found in one patient. One possible etiology is that the fortuitous occurrence of ulceration over an unusually large submucosal artery may cause it to rupture.In making the diagnosis of this disease, attention should be paid to abnormal running of large arteries. It is important to confirm hemorrhagic sites by gastrotomy during surgery. In postoperative period, it is necessary to follow the patients closely keeping in mind the possible recurrence of gastric hemorrhage. In addition to this cases, 107 others reported in Japan were reviewed for clinical evaluation.

A left axillary artery perfusion instead of a femoral perfusion has the benefit of avoiding false lumen perfusion and atheroembolization into the brain, which is caused by retrograde perfusion in type A aortic dissection surgery. We performed type A aortic dissection surgery using the left axillary artery perfusion technique and reviewed this method.From April 2002 to January 2004, 8 patients with a mean age of 70 years (48 to 81), underwent axillary artery cannulation with a side graft technique in type A aortic dissection operations. Six patients had acute type A and 2 had chronic type A dissections. The surgical procedures were ascending aortic replacement in 5, hemiarch replacement in 2, and total arch replacement in 1.In all patients, a cardiopulmonary bypass was established through the left axillary perfusion. There were no operative deaths and no hospital deaths. All patients were able to avoid cerebral vascular accidents. One patient required a femoro-femoro bypass on the 10th postoperative day because of malperfusion of the left leg, which occurred suddenly. Postoperative hemorrhaging requiring resternotomy occurred in 2 patients.A left axillary artery perfusion is safe and useful for arterial inflow for type A aortic dissection surgery.

In cardiac tissues, angiotensin II causes inotropic and chronotropic effects on the heart. It is indicated that the mechanism of the inotropic effect of angiotensin II is attributed to an increase in cytosolic free calcium ([Ca2+]i) in cardiomyocytes. However, increased [Ca2+]i should be restored to a physiological level because cumulative elevation in [Ca2+]i leads to irreversible injury in cardiomyocytes. Whereas it is known that angiotensin II causes the increase in [Ca2+]i in cardiac cells, little is known about the mechanisms of decrease in [Ca2+]i in cardiomyocytes upon angiotensin II stimulation. In the present study, we examined the effect of angiotensin II on Ca2+ efflux from freshly isolated adult rat cardiomyocytes. Angiotensin II stimulated the efflux of 45Ca2+ from the cells in a concentration-dependent manner (10(-7)-10(-5) M). The 45Ca2+ efflux from the cells was inhibited by type 1 angiotensin II receptor inhibitor. The angiotensin II-stimulated 45Ca2+ efflux was not affected by deprivation of the extracellular Ca2+, but was dependent on the presence of extracellular Na+. These results indicate that angiotensin II stimulates extracellular Na(+)-dependent 45Ca2+ efflux from freshly isolated adult rat cardiomyocytes, probably through its stimulatory effect on the plasma membrane type 1 angiotensin II receptors which may couple to Na+/Ca2+ exchange.

The effect of extracellular adenosine 5′-triphosphate (ATP) on Ca 2+ efflux from freshly isolated adult rat cardiomyocytes was examined. ATP stimulated the efflux of 45 Ca 2+ from the cells in a concentration-dependent manner (0.01–1 mM). The 45 Ca 2+ efflux from the cells was also stimulated by adenosine-5′-O-(3-thiotriphosphate) (ATP-γs) and α,β-methylene-ATP and adenosine 5′-diphosphate, but not by adenosine 5′-monophosphate and adenosine. The ATP-stimulated 45 Ca 2+ efflux was not affected by deprivation of the extracellular Ca 2+ , but was dependent on the presence of extracellular Na + . These results indicate that ATP stimulates extracellular Na + -dependent 45 Ca 2+ efflux from freshly isolated adult rat cardiomyocytes, probably through its stimulatory effect on the plasma membrane P 2 purinoceptors which may couple to Na + /Ca 2+ exchange.

In expectation of the growth of a new pulmonary arterial trunk in total correction of tetralogy of Fallot with pulmonary atresia, we used pedicled autologous pericardium combined with left atrial appendage as the posterior wall of a new pulmonary arterial trunk. In cases of long discontinuity between the right ventricular infundibulum and left pulmonary artery, our technique could be recommended for early repair of tetralogy of Fallot with pulmonary atresia.