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Type III endoleaks after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with the Endologix unibody endograft remain a major concern, despite fabric, system, and instructional updates. The purpose of this study was to examine real-world outcomes of repairing AAAs using the current version of the AFX2 main body in combination with an aortic cuff, specifically focusing on type III endoleaks and morphological changes of the endograft.We recruited facilities in Japan that used AFX2 combined with an aortic cuff for at least five cases between April 2017 and March 2018. A total of 175 cases in 24 facilities were analyzed. Patients' background information, including anatomic factors, operative findings, device component variations, and midterm outcomes at 3 years after the EVAR were collected. The data on computed tomography scans from cases registered as types I and III endoleaks and migration from each institute were sent to our department for verification.The mean patient age was 74.6 ± 8.1 years, and 48 cases (27%) were saccular aneurysms. The mean fusiform and saccular AAA diameters were 50.5 ± 5.8 mm and 43.5 ± 8.9 mm, respectively. No in-hospital deaths occurred. Data at 3 years, including computed tomography images, of 128 cases were analyzed. Overall survival, freedom from aneurysm-related mortality, and freedom from reintervention rates at 3 years were 85.8%, 99.3%, and 87.3%, respectively. There were three, one, and three cases of types I, IIIa, and IIIb endoleaks without sac dilatations, respectively. Among five migration cases, one case of aortic cuff migration presented as a type Ia endoleak, and four cases demonstrated sideways displacement, one of which presented as a type IIIa endoleak. The sac regression and enlargement rates at 3 years were 41.4% and 20.5% in the fusiform group and 44.2% and 16.7% in the saccular group, respectively. The proximal neck diameter slightly increased from 20.8 ± 2.7 mm before the EVAR to 22.2 ± 4.6 mm after the repair.Midterm outcomes of the AFX2 used in combination with an aortic cuff were acceptable, considering the rates of types I and III endoleaks. However, there were cases of sideways displacement that could cause future type IIIa endoleaks. When the AFX2 is used in combination with an aortic cuff, close surveillance for endograft deformations and subsequent adverse events, including type III endoleaks, is needed.

Chlorophyllase (CLH) is a common plant enzyme that catalyzes the hydrolysis of chlorophyll to form chlorophyllide, a more hydrophilic derivative. For more than a century, the biological role of CLH has been controversial, although this enzyme has been often considered to catalyze chlorophyll catabolism during stress-induced chlorophyll breakdown. In this study, we found that the absence of CLH does not affect chlorophyll breakdown in intact leaf tissue in the absence or the presence of methyl-jasmonate, which is known to enhance stress-induced chlorophyll breakdown. Fractionation of cellular membranes shows that Arabidopsis (Arabidopsis thaliana) CLH is located in the endoplasmic reticulum and the tonoplast of intact plant cells. These results indicate that CLH is not involved in endogenous chlorophyll catabolism. Instead, we found that CLH promotes chlorophyllide formation upon disruption of leaf cells, or when it is artificially mistargeted to the chloroplast. These results indicate that CLH is responsible for chlorophyllide formation after the collapse of cells, which led us to hypothesize that chlorophyllide formation might be a process of defense against chewing herbivores. We found that Arabidopsis leaves with genetically enhanced CLH activity exhibit toxicity when fed to Spodoptera litura larvae, an insect herbivore. In addition, purified chlorophyllide partially suppresses the growth of the larvae. Taken together, these results support the presence of a unique binary defense system against insect herbivores involving chlorophyll and CLH. Potential mechanisms of chlorophyllide action for defense are discussed.

Yoshihiro Nagata1), Taichi Kato2), Satoru Makita3), Maiko Ikeda1), Yoshie Fukazawa2), Yasuaki Kishimoto2), Atsushi Numaguchi4), and Noriko Nagai1) 1) Department of Pediatrics, Okazaki City Hospital, Aichi, Japan 2) Department of Pediatrics, Graduate School of Medicine, University of Nagoya, Aichi, Japan 3) Department of Pediatric Surgery, Graduate School of Medicine, University of Nagoya, Aichi, Japan 4) Department of Emergency and Critical Care Medicine, Nagoya University Hospital, Aichi, Japan

Purpose: We have been using the flanged composite aortic prosthesis and Carrel button technique to re-attach the coronary ostia in aortic root replacement procedures at our institution over the last twenty five years. Our objective was to evaluate the long-term results of aortic root replacement with this technique. Methods: A total of 73 patients from January 1984 to August 2010 were included in this study. The median age was 52.7 ± 14.4 years (range 28–80 years). There were 48 male and 25 female patients. 44 patients (60.3%) had annuloaortic ectasia, and 15 patients (20.5%) had acute type A aortic dissection. Marfan syndrome was recognized in 12 patients (16.5%). Results: The early mortality rate was 5.5% (n = 4). Causes of death were multiple organ failures in two patients and sepsis in another two patients. The actuarial survival rate was 84.2% at 5 years, 64.3% at 15 years and 51.9% at 25 years. Only one patient with aortitis needed a reoperation because of coronary pseudoaneurysm after 23 years from the previous operation. Conclusion: This modified Bentall procedure is reliable and safe, with superior long-term survival and a low rate of aortic reoperation.

症例は68歳，女性．2002年に急性（下壁）心筋梗塞のために右冠動脈に対してPCI施行され，以後当院外来通院中であった．2007年3月，労作時呼吸苦が出現し，うっ血性心不全の診断で緊急入院した．冠動脈造影検査で重症3枝病変，左室造影では心基部下壁に存在する左室瘤と同瘤を経由し右室への交通を認める心室中隔穿孔を認めた．手術は，心室瘤壁のみを切開し内腔へアプローチした．瘤内から4-0ポリプロピレン糸を用いて穿孔部の単純縫合閉鎖，やや大きめの馬心嚢膜パッチを用いて瘤入口部と正常心筋との境界部を縫合することで瘤入口部閉鎖を行った．また冠動脈バイパス術3枝（左内胸動脈-左前下降枝，大伏在静脈-対角枝-後側壁枝）を併施した．術後第12病日に左室造影とグラフト造影を行い，遺残シャントを認めず瘤も消失しており，グラフトも全て開存していることを確認し，第13病日に軽快退院となった．

The pulmonary artery catheter( PAC) has been used for hemodynamic monitoring in patients undergoing cardiac surgery. Pulmonary artery injury and pseudoaneurysm formation are the most serious and fatal complications of PAC. A 73-year-old female with aortic stenosis and angina underwent aortic valve replacement and coronary artery bypass grafting. PAC was inserted without difficulty before cardiac surgery in the operating room. The operation proceeded uneventfully. On the 1st postoperative day, massive hemoptysis suddenly occurred in the intensive care unit. The patient was treated with mechanical ventilation with positive end expiratory pressure. An enhanced computed tomography scan showed a pulmonary artery pseudoaneurysm, whith was successfully occluded by transcatheter arterial embolization. The patient was discharged in good health.

Objective The objective of the present study was to investigate the effectiveness of postoperative oral administration of cibenzoline for the prevention of atrial fibrillation (AF) in coronary artery bypass grafting (CABG). Methods: A total of 39 patients who underwent isolated CABG from September 2000 to February 2001 and who took oral cibenzoline (300 mg per day for 10 days beginning immediately after surgery) were compared to 59 patients who underwent surgery in our department 8 months prior to the study and who did not take cibenzoline for incidence of postoperative AF. Exclusion criteria encompassed age (>80 years), low ejection fraction ( 2.0 mg/dL), and history of supraventricular arrhythmia with or without treatment by anti-arrhythmic drugs. Results: Postoperative AF occurred in 2 patients in the cibenzoline group (2/35, 5.7%) and 20 patients in the control group (20/59, 33.9%). There were significant differences in the incidence of postoperative AF (p=0.002). Multivariate analysis revealed that the administration of cibenzoline reduced the incidence of AF significantly, and that a large number of bypass grafts significantly contributed to postoperative AF in CABG. The number of bypass grafts was significantly larger in the cibenzoline group, indicating that cibenzoline administration significantly suppresses the incidence of AF after CABG in high-risk patients. Conclusions: Postoperative administration of oral cibenzoline for 10 days is one effective method for the prevention of AF after CABG.

A 76-year-old woman with primary antiphospholipid syndrome (APS) was referred to our hospital due to severe aortic valve stenosis. We performed aortic valve replacement using a bioprosthetic valve. Her postoperative course was uneventful. She was discharged in good health on postoperative day 33. As for cardiovascular operations in APS patients, high rates have been reported of perioperative mortality and thromboembolic and bleeding events. Perioperative management of anticoagulation must be strict.

The number of patients with coexisting cardiac disease and lung cancer have been increasing. The issue of performing simultaneous pulmonary resection and cardiac surgery remains controversial. We report a patient who underwent simultaneous surgery for Ebstein's anomaly and lung cancer with a good outcome. The tricuspid valve replacement with bioprothesis and the closure of a foramen ovale for Ebstein's anomaly was 1st performed under cardiopulmonary bypass. The resection of the right upper pulmonary lobe and mediastinal lymph nodes followed. The postoperative course was uneventful.

Heat flow values have been determined at sites that are densely distributed around biological communities located along a topographic inflection line to the southeast of Hatsushima Island in the western Sagami Bay through four research cruises since 1988. Anomalously high heat flow values up to 2, 000 mW/m2 were observed at the largest community, where a high methane content anomaly had been found indicating fluid venting activity. Within 1 km of the inflection line, which is presumed to be a surface expression of an active fault, heat flow values are high and variable (about 400 mW/m2), whereas they are low and uniform (50 mW/m2) in a flat area more than 1 km away from the inflection line.Since this area is located near a convergent plate boundary and also near the volcanic front of the Izu-Bonin arc, either a seepage of the pore fluid at the inflection line or a conductive heating by the shallow magma intrusion below the community is thought to be a possible cause of the high heat flow anomaly. From simple estimations, however, neither of them was found to be adequate to explain the observation. Probably a pore fluid circulation is occurring in the fault system beneath the community that is possibly driven by a shallow magma below the fault and/or the compressional stress field.

A 69-year-old male who had an abdominal aortic aneurysm with horseshoe kidney is reported. Preoperative 3-dimensional computed tomoangiography (3DCTA) images confirmed two accessory renal arteries diverging from the aneurysm to the isthmus. We operated on the abdominal aortic aneurysm using the left retroperitoneal approach, which provided excellent exposure of the aneurysm without dividing the renal isthmus. This exposure showed us the accessory arteries, so we could easily recognize these arteries visualized by 3DCTA, and we could reconstruct the larger one of two accessory arteries. Preoperative 3DCTA was very useful for the operation of the abdominal aortic aneurysm with horseshoe kidney. The postoperative course was uneventful.