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Surgery for extensive thoracic aortic aneurysms is challenging. We report the case of a young woman with Takayasu’s arteritis who developed aortic dissection and was successfully treated with our novel extended arch repair method, which we termed “parabronchial approach”. Surgery was performed via a simple sternotomy. The left pulmonary artery was compressed caudally by a surgical assistant arm typically used for coronary artery bypass grafting. This method simplified the creation of a distal anastomosis to the descending aorta behind the left bronchus. Postoperative computed tomography revealed a distal anastomosis at the sixth thoracic vertebra This parabronchial approach could reduce the frequency of choosing a highly invasive approach and can be a potential minimally invasive approach in cases requiring extensive thoracic aortic aneurysm repair.

Introduction: Neurologic complications of open thoracic aortic surgery are devastating problems in patients with severely diseased aortas. This study aimed to clarify whether directing the aortic cannula tip toward the aortic root affects the postoperative cardiac function in patients undergoing open thoracic aortic surgery. Methods: A total of 16 patients who underwent total or partial arch replacement between January 2014 and April 2019 were enrolled and divided into two groups. Ascending aorta perfusion was performed by placing the cannula tip toward the aortic root (reversed direction group, seven patients) or toward the aortic arch (standard direction group, nine patients). Intraoperative and perioperative data, including mortality, morbidity, and postoperative cardiac function, were compared between the groups. Results: There were no hospital deaths or stroke events in either group. The aortic cross-clamping time was 102.4 ± 20.3 minutes in the reversed direction group and 87.1 ± 9.9 minutes in the standard direction group (p = 0.049). Furthermore, the intubation time was 28.4 ± 12.9 hours in the reversed direction group and 12.4 ± 6.8 hours in the standard direction group (p = 0.022). Both times were significantly longer in the reverse direction group. Postoperative serum creatine kinase-MB levels were significantly lower in the reversed direction group (6.2 ± 3.3 U/L vs 13.3 ± 4.8 U/L, respectively, p = 0.006). The cardiac output and cardiac index did not significantly differ. Conclusions: Directing the aortic cannula tip toward the aortic root does not adversely affect the postoperative cardiac function after aortic arch surgery.

A 74-year-old woman developed inferior myocardial infarction due to right coronary artery occlusion and underwent percutaneous coronary intervention. Two days later, echocardiography revealed ventricular septal rupture, and Impella CP was inserted to avoid emergency surgery. However, the patient's hemodynamics deteriorated rapidly, necessitating additional venoarterial extracorporeal membranous oxygenation support with concomitant Impella support (ECPELLA). The ventricular septal rupture was surgically repaired using the extended sandwich technique via a right ventricular approach; the ascending aorta was clamped with the clampable portion of the Impella. The patient was successfully weaned from the Impella 3 days postsurgery. This case suggests that urgent surgery with ECPELLA support could be a useful option for patients with ventricular septal rupture, even in severe cases wherein emergency surgery is unavoidable.

Using autologous common femoral artery and external oblique muscle fascia is a simple and reliable option for repairing infected aortic pseudoaneurysms. Reoperation of infected pseudoaneurysms is challenging and requires secure aortic repair with complete infection eradication. Here, we report two cases of infected pseudoaneurysms in the ascending aorta cannulation site after cardiac surgeries. Common femoral arteries and fascia were harvested in the same lesion as repair materials. The aortic pseudoaneurysms were repaired under deep hypothermic circulatory arrest. Femoral arterial patches were reinforced with circumferential aponeurosis strips. There was no infection recurrence or repair site dilatation in the long-term follow up of both patients.

Background Inhaled nitric oxide (NO) is often used postoperatively for pediatric pulmonary hypertension (PH). Although the use of postoperative inhaled NO for adult cases has become prevalent, the Asian data of such cases are limited. This study aimed to evaluate the safety and effectiveness of NO inhalation therapy for PH in adult patients after mitral valve surgery. Methods In this retrospective study, we enrolled 24 adult patients with a mean pulmonary artery pressure (mPAP) > 25 mmHg after mitral valve surgery at our institution from January 2017 to September 2020. Among these patients, NO was used postoperatively (NO group) in 13, whereas NO was not used in 11 (non-NO group). We compared the clinical data, such as age, preoperative echocardiogram, cardiac catheterization results, perioperative information, postoperative Swan-Ganz catheter data, tracheal intubation time, and length of stay in the intensive care unit (ICU). Results The NO group had higher tricuspid regurgitation pressure gradient, right atrial pressure, and pulmonary artery wedge pressure, as well as more surgically complex cases, than the non-NO group. There were no differences in operative and aortic cross-clamp time, tracheal intubation duration, or length of ICU stay. In the NO group, the mPAP decreased and the cardiac index increased after postoperative NO inhalation. However, there were no significant differences in the mPAP and cardiac index between the NO and non-NO groups. Conclusions Our results suggest that NO inhalation therapy was not associated with shorter postoperative intubation and ICU stay in adult patients with PH after mitral valve surgery. These findings support those of studies from other countries, yet they do not clarify the usefulness of inhaled NO in these cases. Optimal NO therapeutic strategies should be reconsidered with the goal of reducing intubation time and length of stay in the ICU.

A 35-year-old man presented with an anomalous right coronary artery from the opposite Valsalva sinus. He developed an aorto-right-atrial fistula due to destructive infective endocarditis undetected during preoperative computed tomography. Intraoperative retrograde cardioplegia and direct insertion of the coronary probe demonstrated that the right coronary ostium was in the left Valsalva sinus near the left coronary ostium. The right-sided aortic root and right atrium were severely damaged. This coronary anomaly allowed us to perform a unique aortic root reconstruction without touching or injuring the right coronary artery. Two years later, the patient remains well without complications. This novel reconstruction treatment is feasible for destructive infective endocarditis in such patients.

The patient was a 12-year-old female who presented with angina pectoris, aortic root dilatation, and aortic regurgitation (AR) caused by Takayasu's arteritis (TA). After the management of systemic inflammation, she underwent off-pump coronary artery bypass with the radial artery (RA), which extended from the left axillary artery to the left descending coronary artery, via left mini-thoracotomy. Postoperative angiography revealed the growth of the RA graft. The patient is well 4 years after surgery without progression of AR. Off-pump coronary artery bypass is a palliative therapy. Moreover, it could be a feasible option in a child with TA involving the aortic root.

Highlights • Middle aortic syndrome (MAS) combined with thoracic aortic aneurysm (TAA) is a rare vascular disease. • Combined operation of total arch replacement and a bypass from the ascending aorta to the bifemoral arteries is alternative for MAS combined with TAA. • One stage open surgery got good clinical outcome for this condition without any another intervention postoperative., Introduction: Middle aortic syndrome (MAS) combined with thoracic aortic aneurysm (TAA) is a rare vascular disease. One stage open surgery to treat this condition, becomes a challenge for our cardiovascular surgery. Presentation of case: A 69-year-old man presented with a saccular type aortic arch aneurysm, shaggy aorta and severe atherosclerotic stenosis of the thoracoabdominal aorta with middle aortic syndrome and aberrant right subclavian artery, renovascular hypertension, renal dysfunction, and intermittent claudication of both legs. Total arch replacement procedure was performed under a cardiopulmonary bypass using aortic inflow from the right axillary artery and a femoro-femoral crossover bypass graft to avoid malperfusion of the lower body. Before weaning from the cardiopulmonary bypass, we established an extra-anatomical bypass from the ascending aortic graft to the femoro-femoral crossover bypass graft. 3D-CT showed patency of bypass graft without any sign of stenosis postoperative. The patient’s postoperative course was uneventful and he was discharged from hospital with improvements in intermittent claudication, hypertension, and renal dysfunction. Discussion: Although open surgery including graft bypass for MAS is more invasive than endovascular treatment, it could be performed successfully to preventing from intraoperative complication or complications postoperatively. Conclusion: Combined operation of total arch replacement and a bypass from the ascending aorta to the bifemoral arteries is alternative for MAS combined with TAA.

Since aortic valve stenosis (AVS) is the most frequent and serious valvular heart disease in the elderly, and is accompanied by irreversible valve calcification, medicinal prevention of AVS is important. Although we recently demonstrated that human aortic valve interstitial cells (HAVICs) obtained from patients with AVS were highly sensitive to ectopic calcification stimulation, the cell types contributing to calcification are unknown. We aimed to immunocytochemically characterize HAVICs and identify their contribution to valve calcification. HAVICs were isolated from patients with AVS and cultured on non-coated dishes. Immunocytochemical features and HAVIC differentiation were analyzed in passage 1 (P1). The immunohistochemical features of the calcified aortic valve were analyzed. Most cultured P1 HAVICs were CD73-, CD90-, and CD105-positive, and CD45-and CD34-negative. HAVICs were vascular endothelial growth factor receptor 2 (VEGFR2)-positive; however, approximately half were α-smooth muscle actin (SMA)-positive, colonized, and easily differentiated into osteoblastic cells. Calcified aortic valve immunohistochemistry showed that all cells were positive for VEGFR2 and partly α-SMA. Further, VEGFR2-positive cells were more sensitive to tumor necrosis factor-α-induced ectopic calcification with or without α-SMA positivity. We conclude that HAVICs obtained from patients with AVS are VEGFR2-positive undifferentiated mesenchymal cells and may contribute to aortic valve ectopic calcification.

Objective We evaluated additional pulmonary blood flow at the time of bidirectional cavopulmonary shunt and its effects on the Fontan procedure and long-term outcome of Fontan circulation and liver function. Methods We included 22 patients (16 boys, 6 girls) having undergone bidirectional cavopulmonary shunt with additional pulmonary blood flow between April 2002 and January 2016. Mean age and body weight were 20 ± 13 months and 7.5 ± 6.5 kg, respectively. We retrospectively evaluated the patients’ clinical data, including cardiac catheterization data, liver function, and liver fibrosis markers. Results All patients were alive with a New York Heart Association status of I at the long-term follow-up. Changes between pre-bidirectional cavopulmonary shunt and 101 months after the Fontan procedure included the following: the cardiothoracic ratio of chest X-ray decreased from 52.2 ± 3.9% to 41.8 ± 5.9% (p p p = 0.02). Type IV collagen, hyaluronic acid, and procollagen levels increased over the normal range 116 months after the Fontan procedure. Conclusions The additional pulmonary blood flow at the time of bidirectional cavopulmonary shunt may contribute to pulmonary arterial growth at the Fontan procedure with low pulmonary arterial resistance and without ventricle volume overload. The Fontan circulation was well-maintained at the long-term follow-up, while liver fibrosis markers were above their normal values.

Introduction: Cerebral injury is a serious complication in open-heart surgery. Once it occurs, it causes significant disability and death. We developed a novel dispersive aortic cannula named the Stealth Flow cannula and used it as a standard aortic cannula in cardiopulmonary bypass. The aim of this study was to evaluate the efficiency of this aortic cannula. Methods: A total of 182 consecutive patients undergoing cardiac surgery using cardiopulmonary bypass were studied. The patients were divided into two groups: the Soft-Flow cannula group (n = 89) and the Stealth Flow cannula group (n = 93). Patients with a shaggy aortic arch were excluded from this study because the cannulae were inserted at the ascending aorta with a cannula tip directed toward the aortic root in these cases. Patients with multiple arterial perfusion sites were also excluded. Complications including early mortality, perioperative stroke, and intraoperative aortic injury were compared between the two groups. Results: Age, operative procedure, cardiopulmonary bypass time, and the Japan SCORE were not significantly different between the groups. In comparisons between the Stealth Flow and Soft-Flow groups, the incidences of early mortality, perioperative stroke, intraoperative aortic dissection, and all complications were 1.08% versus 1.12% (p = 0.98), 1.1% versus 2.2% (p = 0.53), 0% versus 1.1% (p = 0.33), and 1.1% versus 3.4% (p = 0.29), respectively. The incidence of major cardiovascular events, including early death, perioperative stroke, and aortic dissection, was not different. Conclusions: The Stealth Flow cannula, which was designed based on our previous experimental study, contributed to reducing cerebral and aortic events as much as the Soft-Flow cannula in the present clinical study.

In the original publication of the article, part of Fig. 1 was published incorrectly.

Background Acute pulmonary embolism (PE) is a major threat to the health and lives of hospitalized patients. This study was conducted to clarify the real-world outcomes of pulmonary embolectomy.Methods and Results:Retrospective investigation of 355 patients who underwent pulmonary embolectomy for acute PE was conducted using the Japanese Cardiovascular Surgery Database. Risk factors for operative death within 30 days after pulmonary embolectomy and major adverse cardiovascular events (MACE), including operative death, postoperative stroke and postoperative coma, were analyzed. Cardiopulmonary resuscitation (CPR) was required preoperatively in 27.6%, and preoperative veno-arterial extracorporeal membrane oxygenation was performed in 26.5%. Urgent or emergency operation was performed in 93% of patients. Operative mortality rate was 73/355 (20.6%). Incidence of MACE was 97/355 (27.3%). In univariate analysis, preoperative predictors of death were obesity, renal dysfunction, chronic obstructive pulmonary disease, liver injury, recent myocardial infarction, shock, refractory shock, CPR, heart failure, inotrope use, poor left ventricular function, preoperative arrhythmia and tricuspid regurgitation. In multivariate analysis, independent risk factors for operative death were heart failure (P=0.013), poor left ventricular function (P=0.007), and respiratory failure (P=0.001). Poor left ventricular function (P=0.033), preoperative CPR (P=0.002) and respiratory failure (P=0.007) were independent risk factors for MACE. Conclusions The outcomes of pulmonary embolectomy were acceptable, considering the urgency and preoperative comorbidities of patients. Early triage of patients with hemodynamically unstable PE is important.

Background: Venous drainage in cardiopulmonary bypass is a very important factor for safe cardiac surgery. However, the ideal shape of venous drainage cannula has not been determined. In the present study, we evaluated the effect of side-hole number under fixed total area and venous drainage flow to elucidate the effect of increasing the side-hole numbers. Method: Computed simulation of venous drainage was performed. Cannulas were divided into six models: an end-hole model (EH) and models containing four (4SH), six (6SH), eight (8SH), 10 (10SH) or 12 side-holes (12SH). Total orifice area of the side-holes was fixed to 120 mm2 on each side-hole cannula. The end-hole orifice area was 36.3 mm2. The total area of the side-holes was kept constant when the number of side-holes was increased. Result: The mean venous drainage flow rate of the EH, 4SH, 6SH, 8SH, 10SH and 12SH was 2.57, 2.52, 2.51, 2.50, 2.49, 2.41 L/min, respectively. The mean flow rate decreased in accordance with the increased number of side-holes. Conclusion: We speculate that flow separation at the most proximal site of the side-hole induces stagnation of flow and induces energy loss. This flow separation may hamper the main stream from the end-hole inlet, which is most effective with low shear stress. The EH cannula was associated with the best flow rate and flow profile. However, by increasing side-hole numbers, flow separation occurs on each side-hole, resulting in more energy loss than the EH cannula and flow rate reduction.

Acute pulmonary thromboembolism is a catastrophic event, especially for hospitalized patients. The prognosis of pulmonary thromboembolism depends on the degree of pulmonary arterial occlusion. The mortality of massive pulmonary embolism is reportedly as high as 25% without cardiopulmonary arrest and 65% with cardiopulmonary arrest. In patients with unstable hemodynamics due to pulmonary thromboembolism, surgical pulmonary embolectomy is indicated for patients with a contraindication to thrombolysis, failed catheter therapy, or failed thrombolysis. Thrombolytic therapy adds an additional burden on patients who are at risk of potential hemorrhagic complications. It is also indicated if patients are already on a veno-arterial extra-corporate membrane oxygenator for circulatory collapse or cardiopulmonary arrest. The outcome for patients who require cardiopulmonary resuscitation for longer than 30 minutes is poor. Therefore, early triage for massive and sub-massive pulmonary embolism is crucial. A team approach including a cardiovascular surgeon may be effective to save critically ill patients. Prompt removal of emboli reduces the right ventricular load with quick recovery of cardiopulmonary function in the early postoperative period. A recent series reported excellent results, with in-hospital mortality of less than 10%. Surgical pulmonary embolectomy is an effective, safe, and easy procedure to save critical patients due to pulmonary thromboembolism.

Background: The incidence of pulmonary thromboembolism has been considered rare in Japan. However, its occurrence has been increasing because of westernized lifestyle and diet, increased diagnostic technique, and recognition of this disease. Method: Between January 2003 and September 2014, 179 patients were treated for pulmonary thromboembolism. We classified these patients into 3 groups; Massive (n=35), Sub-massive (n=29) and Nonmassive (n=115) and retrospectively reviewed the treatment options and the outcome. Results: Percutaneous cardiopulmonary support (PCPS) was applied for patients with hemodynamic instability and IVC filter was inserted if there was proximal DVT. In non-massive group (n=115), 95.7% of the patient underwent anticoagulant therapy and 47.0% of the patients received IVC filter. In submassive group (n=29), 48.3% of the patient received thrombolytic therapy and 93.1% of the patient underwent IVC filter insertion. Surgical pulmonary embolectomy was performed in 3 patients who had high risk of thrombolytic therapy in submassive group. There was no death in this group. In massive group, 4 patients who had cardiogenic shock died in acute phase. PCPS was applied in 5 patients, pulmonary embolectomy was performed in 13 patients, thrombolytic therapy was performed in 4 patients and 13 patients underwent anticoagulant therapy alone. There were 7 deaths (20.0%) in this group. Conclusions: In submassive group, treatment should be decided depending on the bleeding risk. In massive group, pulmonary embolectomy was effective. (This is a translation of Jpn J Phlebol 2016; 27: 53-59.).

A 4-year-old boy with acute lymphocytic leukaemia presented with left hemiplegia during chemotherapy. Computed tomography revealed cerebral infarction, and an echocardiogram showed vegetation in the right and left ventricles. Despite antifungal therapy, he experienced another stroke; and 9 days after the first stroke, he underwent total extirpation of the vegetative nodules and fragile vegetation. The postoperative course was unremarkable with no recurrence of infective endocarditis. Although a bacterial culture of the vegetation could not identify the presence of any organism, a pathological specimen examination revealed Cryptococcus with a round and mucinous capsule.

Recently, we confirmed that in human aortic valve interstitial cells (HAVICs) isolated from patients with aortic valve stenosis (AVS), calcification is induced in high inorganic phosphate (high-Pi) medium by warfarin (WFN). Because WFN is known as a vitamin K antagonist, reducing the formation of blood clots by vitamin K cycle, we hypothesized that vitamin K regulates WFN-induced HAVIC calcification. Here, we sought to determine whether WFN-induced HAVIC calcification in high-Pi medium is inhibited by menaquinone-4 (MK-4), the most common form of vitamin K2 in animals. HAVICs obtained from patients with AVS were cultured in α-modified Eagle's medium containing 10% FBS, and when the cells reached 80%-90% confluency, they were further cultured in the presence or absence of MK-4 and WFN for 7 days in high-Pi medium (3.2 mM Pi). Intriguingly, in high-Pi medium, MK-4 dose-dependently accelerated WFN-induced HAVIC calcification and also accelerated the calcification when used alone (at 10 nM). Furthermore, MK-4 enhanced alkaline phosphatase (ALP) activity in HAVICs, and 7 days of MK-4 treatment markedly upregulated the gene expression of the calcification marker bone morphogenetic protein 2 (BMP2). Notably, MK-4-induced calcification was potently suppressed by two pregnane X receptor (PXR) inhibitors, ketoconazole and coumestrol; conversely, PXR activity was weakly increased, but in a statistically significant and dose-dependent manner, by MK-4. Lastly, in physiologic-Pi medium, MK-4 increased BMP2 gene expression and accelerated excess BMP2 (30 ng/ml)-induced HAVIC calcification. These results suggest that MK-4, namely vitamin K2, accelerates calcification of HAVICs from patients with AVS like WFN via PXR-BMP2-ALP pathway. SIGNIFICANCE STATEMENT: For aortic valve stenosis (AVS) induced by irreversible valve calcification, the most effective treatment is surgical aortic or transcatheter aortic valve replacement, but ∼20% of patients are deemed unsuitable because of its invasiveness. For effective drug treatment strategies for AVS, the mechanisms underlying aortic valve calcification must be elucidated. Here, we show that menaquinone-4 accelerates warfarin-induced calcification of AVS-patient human aortic valve interstitial cells in high inorganic phosphate medium; this effect is mediated by pregnane X receptor-bone morphogenetic protein 2-alkaline phosphatase signaling, which could be targeted for novel drug development.

The impact of kinking of the nonstented part of a frozen elephant trunk on the development of adverse effects is unclear. We report a case of an infected thrombus within the kinked nonstented portion of the frozen elephant trunk that resulted in multiorgan embolization. A 45-year-old man presented with a 1-month history of high-grade fever and fatigue. He had undergone emergent total arch replacement and frozen elephant trunk implantation for type A acute aortic dissection 7 years previously. Computed tomography showed an intraluminal thrombus within the kinked nonstented portion of the frozen elephant trunk. An autopsy also showed an intraluminal thrombus within the graft and diffuse microembolization in the abdominal organs. Therefore, in this case, kinking of the nonstented part of the frozen elephant trunk had resulted in an infected intraluminal thrombus, which subsequently caused multiorgan embolization.

A 13-year-old boy presented with right atrial aneurysm and downward displacement of the anterior leaflet in the tricuspid valve into the right ventricle, without tricuspid valve regurgitation. Paroxysmal atrial flutter was caused by an abnormal electrical re-entry circuit, which could not be treated using catheter radiofrequency ablation. Therefore, the patient underwent surgical ablation and resection of the enlarged right atrial wall. The anterior leaflet of the tricuspid valve was plastered and displaced downward into the right ventricle, which resembled Ebstein's anomaly. Pathological evaluation revealed a thin wall that contained fibrous tissue with lipomatous degeneration and few muscular elements. No postoperative arrhythmia was observed.

An abnormally high serum phosphate level induces calcific aortic stenosis (CAS), which is characterized by ectopic valve calcification and stenosis of the orifice area. Inhibition of ectopic calcification is a critical function of any internal medical therapy for CAS disease. The aim of the present study was to investigate the inhibitory effects of several derivatives of evocarpine, methanolic extracts from the fruits of Evodia rutaecarpa Bentham (Japanese name: Go-Shu-Yu) on the high phosphate-induced calcification of human aortic valve interstitial cells (HAVICs) obtained from patients with CAS. High phosphate (3.2 mM) concentrations significantly increased the calcification of HAVICs after 7 days of culture. This calcification was completely inhibited in the presence of sodium phosphonoformate (PFA), a selective inhibitor of the type III sodium-dependent phosphate cotransporter (PiT-1). PiT-1 contributes to phosphate uptake, resulting in calcification. 1-Methyl-2-undecyl-4(1 H )-quinolone (MUQ; 30–300 nM), but not evocarpine or its derivatives dihydroevocarpine and 1-methyl-2-nonyl-4(1 H )-quinolone, inhibited the high phosphate-induced HAVICs calcification in a concentration-dependent manner. Although all of the evocarpine derivatives attenuated alkaline phosphatase activity, only MUQ also decreased PiT-1 gene expression with cellular PiT-1 protein diminution. These results suggest that MUQ mitigated high phosphate-induced HAVICs calcification by inhibiting PiT-1 gene expression.

The patient was a 68-year-old woman with a history of multiple cerebral emboli. The patient presented with dysarthria, dysphagia, and left facial paralysis. Emergent MRI demonstrated multiple emboli in the brain stem and left occipital lobe. Echocardiography and chest CT demonstrated floating emboli entrapped in the foramen ovale and pulmonary emboli in both main pulmonary arteries. Emergent pulmonary embolectomy and extraction of the emboli on the foramen ovale were successfully performed without neurological exacerbation.

Warfarin, a vitamin K antagonist, is the most common anticoagulant used to prevent thromboembolisms associated with atrial fibrillation or following valvular surgery. Although several studies have revealed that long-term warfarin use accelerates aortic valve calcification and the development of aortic stenosis (AS), the detailed mechanism for this phenomenon remains unclear. Therefore, our aim was twofold: to establish the conditions for warfarin-induced calcification of human aortic valve interstitial cells (HAVICs) using high-inorganic phosphate (Pi) conditions and to investigate the underlying mechanism. We prepared and cultured HAVICs from aortic valves affected by calcific aortic valve stenosis (AS group) and aortic valves affected by aortic regurgitation but without any signs of calcification (non-AS group). Under Pi concentrations of 3.2 mM, warfarin significantly increased the calcification and alkaline phosphatase (ALP) activity of AS but not non-AS group HAVICs. Furthermore, gene expression of bone morphogenetic protein 2 (BMP2), a calcigenic marker, was significantly increased following 7 days of warfarin treatment. Warfarin-induced calcification of AS group HAVICs at 3.2 mM Pi was significantly inhibited by dorsomorphin, a Smad inhibitor, and the pregnane X receptor (PXR) inhibitors, ketoconazole and coumestrol, but was unaffected by SN-50, an NF-κB inhibitor. Warfarin was also able to increase BMP2 gene expression at a physiological Pi concentration (1.0 mM). Furthermore, excess BMP2 (30 ng/mL) facilitated warfarin-induced ALP upregulation and HAVIC calcification, an effect which was significantly reduced in the presence of coumestrol. Together, our results suggest that warfarin accelerates calcification of HAVICs from AS patients via the PXR–BMP2–ALP pathway.

We report a simple endovascular repair for symptomatic aberrant right subclavian artery (ARSA) in an 11-year-old girl. She had undergone tracheostomy due to hypoxic encephalopathy after cardiac surgery and suffered from dyspnea. Computed tomography revealed tracheal stenosis caused by a vascular ring made with an ARSA and the right common carotid artery. Transcatheter ARSA embolization using an Amplatzer vascular plug and coils was performed. Symptoms improved within a few days after this intervention and no complications such as upper extremity ischemia were encountered. Computed tomography showed the ARSA around the trachea had reduced in size and tracheal stenosis was improved.

Dynamic cardiomyoplasty is a surgical treatment that utilizes the patient's skeletal muscle to support circulation. To overcome the limitations of autologous skeletal muscles in dynamic cardiomyoplasty, we studied the use of a wrapped-type cardiac supporting device using pneumatic muscles. Four straight rubber muscles (Fluidic Muscle, FESTO, Esslingen, Germany) were used and connected to pressure sensors, solenoid valves, a controller and an air compressor. The driving force was compressed air. A proportional-integral-derivative system was employed to control the device movement. An overflow-type mock circulation system was used to analyze the power and the controllability of this new device. The device worked powerfully with pumped flow against afterload of 88 mmHg, and the beating rate and contraction/dilatation time were properly controlled using simple software. Maximum pressure inside the ventricle and maximum output were 187 mmHg and 546.5 ml/min, respectively, in the setting of 50 beats per minute, a contraction/dilatation ratio of 1:2, a preload of 18 mmHg, and an afterload of 88 mmHg. By changing proportional gain, contraction speed could be modulated. This study showed the efficacy and feasibility of a pneumatic muscle for use in a cardiac supporting device.

We describe a new surgical procedure for the scimitar syndrome using the walls of the right atrium and inferior vena cava as a flap to prevent kinking and stenosis of the scimitar vein-left atrium anastomosis.

Calcified aortic valve stenosis (CAS) is a common heart valve disease in elderly people, and is mostly accompanied by ectopic valve calcification. We recently demonstrated that tumor necrosis factor-α (TNF-α) induces calcification of human aortic valve interstitial cells (HAVICs) obtained from CAS patients. In this study, we investigated the role of matrix Gla protein (MGP), a known calcification inhibitor that antagonizes bone morphogenetic protein 2 (BMP2) in TNF-α-induced calcification of HAVICs. HAVICs isolated from aortic valves were cultured, and calcification was significantly induced with 30 ng/mL TNF-α. Gene expression of the calcigenic marker, BMP2, was significantly increased in response to TNF-α, while the gene and protein expression of MGP was strongly decreased. To confirm the role of MGP, MGP-knockdown HAVICs and HAVICs overexpressing MGP were generated. In HAVICs, in which MGP expression was inhibited by small interfering RNA, calcification and BMP2 gene expression were induced following long-term culture for 32 days in the absence of TNF-α. In contrast, HAVICs overexpressing MGP had significantly decreased TNF-α-induced calcification. These results suggest that MGP acts as a negative regulator of HAVIC calcification, and as such, may be helpful in the development of new therapies for ectopic calcification of the aortic valve. Keywords: Aortic valve stenosis, Human aortic valve interstitial cells, Matrix Gla protein, Aortic valve calcification

Cardiac surgery on a patient with cold agglutinin disease is high risk for thromboembolism due to hypothermia perioperative. A 75-year-old woman with cold agglutinin disease underwent aortic valve replacement for severe aortic stenosis. Cold antibody was detected by preoperative screening test for blood transfusion. In order to prevent thromboembolic event during the operation, we maintained rectal temperature at around 36 degrees centigrade during the cardiopulmonary bypass by warming blood in the bypass circuit. Furthermore, antegrade warm blood cardioplegia was injected intermittently for keeping cardiac arrest. There was no thromboembolic event perioperatively.