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We report a case in which infarct exclusion technique was used to repair residual shunt after extended sandwich patch technique for postinfarction ventricular septal perforation (VSP). A 76-yearold woman was diagnosed with postinfarction VSP and underwent extended sandwich patch technique through right ventriculotomy on the third day after the onset of VSP. No residual shunt was then observed by intraoperative transesophageal echocardiography, but a slight residual shunt was observed on the 7th day after operation. She had no symptom of cardiac failure, and was followed up. However, the residual shunt worsened, and she developed cardiac failure on the 48th day after the initial operation. An additional operation by infarct exclusion technique was performed. No residual shunt was observed after the additional operation. She has been doing well with no signs of cardiac failure.

A thoracic aortic thrombus is rare. The causes of this condition and the feasible options for its treatment remain controversial. Preventing embolic complications are the most important for the management of thoracic aortic thrombi. Herein, we report a case of a giant protruding thrombus in the thoracic aorta. We suggest total arch replacement (TAR) using an open stent graft (OSG) as a favorable management technique for thoracic aortic thrombi. We also recommend bilateral axillary artery cannulation to prevent cerebral infarction.

A 60-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) combined with organic mitral regurgitation underwent transmitral septal myectomy and mitral valve plasty. Although a transaortic septal myectomy (Morrow's procedure) is generally accepted as the standard surgical treatment for HOCM, it may be difficult to perform sufficient septal myectomy for mid-ventricular obstructive hypertrophic cardiomyopathy and apical hypertrophic cardiomyopathy (HCM). The transmitral approach with temporary detachment of the anterior mitral leaflet provides a good surgical view in the left ventricle, which allows sufficient septal myectomy from the outflow tract to the apex.

Background The number of dialysis patients in Japan is rising, with an increasing number requiring cardiovascular surgery. Methods We investigated the short- and long-term outcomes in 70 dialysis patients among a total of 1124 who underwent cardiovascular surgery in our hospital between 2004 and 2016. We investigated outcomes following open surgery and identified factors that affected the prognosis. We also compared the long-term survival rate with the survival rate of the Japanese dialysis population. Results The long-term survival rate was 70.6%, 51.1%, and 19.2% after 3, 5, and 10 years, respectively. The causes of long-term death were heart disease in 8 patients, cerebrovascular disease in 7, cachexia in 3, infection in 2, and other causes in 3. The freedom from cardiac death was 88.7%, 77.9%, and 54.9% after 3, 5, and 10 years, respectively. Multivariate analysis using Cox’s proportional hazard model showed that a history of atherosclerosis obliterans (hazard ratio 5.4, p = 0.05) and mediastinitis (hazard ratio 10.2, p = 0.03) were risk factors for death in long-term follow-up, and a history of atherosclerosis obliterans was an independent risk factor for cardiac death in long-term follow-up (hazard ratio 5.3, p = 0.01). Five-year survival of the study subjects was comparable to that of the Japanese dialysis population. Conclusions The prognosis for dialysis patients after open surgery was equivalent to that of Japanese dialysis patients in general. A high proportion of late postoperative deaths were due to heart disease. Patients with atherosclerosis obliterans had a poor prognosis.

Background Total aortic arch replacement is associated with considerable mortality and morbidity. Although operative death is the most extreme adverse clinical end point, postoperative morbidity can also be devastating for survivors. Methods We examined the short-term and long-term outcomes of 146 patients who underwent total aortic arch replacements between September 2003 and September 2011. Results The overall in-hospital mortality was 4.8%, and major postoperative morbidity during hospitalization occurred in 29 patients (19.9%). Multivariate analyses demonstrated that risk factors for hospital death were left thoracotomy (odds ratio [OR], 51.92; p = 0.01), high preoperative serum creatinine values (OR, 3.88; p = 0.02), and intraoperative blood loss (OR, 1.01; p = 0.04). Ruptured aorta (OR, 7.13; p = 0.02) and previous myocardial infarction (OR, 5.13; p = 0.04) were identified as independent risk factors for major postoperative morbidity. The postoperative survival of all patients at 5 years was 76.7% ± 5%. After hospital discharge, the standardized mortality ratios showed no significant difference between hospital survivors and a comparable Japanese population and were 1.09 ( p = 0.41) among patients without major morbidity and 1.82 ( p = 0.12) among those with major morbidity. The development of renal failure requiring hemodialysis increased the risk of long-term death (hazard ratio, 5.59; p = 0.03), even among hospital survivors. Conclusions Our approach for total arch replacement resulted in low in-hospital mortality and morbidity. Long-term outcomes are stable in hospital survivors, especially in the absence of a postoperative requirement for dialysis.

Objective: It is well known that the presence of carotid artery stenosis increases the risk of perioperative stroke in patients undergoing cardiac surgery with cardiopulmonary bypass. Although off-pump coronary artery bypass grafting (CABG) can avoid the adverse effects of cardiopulmonary bypass, the influence of carotid artery stenosis on the incidence of stroke in patients undergoing off-pump CABG has not been well clarified.Methods:We conducted a retrospective study of 461 patients who underwent elective off-pump CABG after screening for carotid artery stenosis at our institute between September 2004 and May 2007. The incidence and etiologies of stroke were identified. Preoperative screening revealed significant carotid artery stenosis in 49 patients. Clinical results were compared between patients with and without carotid artery stenosis. Results: Postoperative stroke occurred in two (0.43%) of the 462 study patients, and in-hospital mortality occurred in three (0.65%). Stroke was due to decreased perfusion resulting from hypovolemic shock in one and thrombosis in the other. There was neither stroke nor inhospital mortality in patients with carotid artery stenosis, although there were two strokes (0.49%) and three in-hospital mortalities (0.73%) in patients without carotid artery stenosis. Conclusions: The influence of carotid artery stenosis on the incidence of perioperative stroke may be little in off-pump CABG, especially in patients with moderate carotid artery stenosis. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Background. Peripheral leukocytes and platelets (LAPs) contain many kinds of cells with the ability to secrete several growth factors and cytokines. We attempted to induce therapeutic angiogenesis by injecting self-LAPs into a rat ischemic hindlimb model. Materials and methods. Supernatants from cultured LAPs were used for the endothelial cell (EC) proliferation assay, and LAPs were used in a cornea model to evaluate angiogenic potency. LAPs were injected directly into the male Dark Agouti rat ischemic hindlimb model, after which a microangiogram was done and the capillary/muscle fiber ratio was examined histologically. ELISA revealed the levels of contributing growth factors and cytokines present in the ischemic muscles. Results. The EC proliferation assay showed that the supernatants of LAPs accelerated proliferation and that the LAPs induced angiogenesis in the cornea model. The microangiograms and histological evaluation revealed that angiogenesis was induced more effectively in the rats injected with LAPs (LAP group) than in the those injected with phosphate-buffered saline (PBS group). The levels of basic fibroblast growth factor (bFGF) in the ischemia, PBS, and LAP groups were significantly increased compared to those in the sham group. The level of interleukin-1β (IL-1β) in the LAP group was significantly more elevated than in the other groups. Conclusions. The injection of self-LAPs induced angiogenesis in a rat ischemic hindlimb model. Ischemia caused an elevation in the level of bFGF and also in IL-1β derived from LAPs, which contributed to angiogenesis. This is a novel, yet simple and safe method of inducing therapeutic angiogenesis.

症例は60歳の男性. 7日前にヒラメの煮付けを食べた際咽頭から喉頭にかけての不快感が自覚された.その2日後より発熱と胸部不快感が出現したため近医を受診し,扁桃炎として治療を受けたが,症状は改善しなかった.初診日昼食摂取後に強度の心窩部痛が出現し,当院救急外来へ搬送された.食道穿孔による急性縦隔炎の診断のもとに緊急手術が施行された.穿孔部が不明なため縫合閉鎖は行われず,頸部および腹部の2方向からの縦隔ドレナージが施行された.術後9日目に頸部食道の穿孔部が明らかになり,また両側の胸膜外膿瘍腔の形成が認められたため, T-tubeを用いた食道外瘻造設術と胸膜外膿瘍腔ドレナージ術が施行された.その後MRSA縦隔炎を併発し治療に難渋するも,さらなる2度の追加手術を行い救命ができた.魚骨による食道穿孔治療は開始時期,選択された治療法により不幸な転帰を辿ることの多い疾患とされている.文献的考察を含めて報告する.

We describe a rare case of an ascending aortic pseudoaneurysm 31 years after mitral valve replacement with a Björk-Shiley mechanical valve. The aneurysm presumably expanded gradually during the years following surgery. As the valve was functioning normally, it was left in situ while the ascending aorta was replaced. This report provides valuable information regarding the long-term nature of this patient’s pseudoaneurysm, and the long-term durability of the Björk-Shiley spherical valve in the mitral position.

A 78-year-old woman with an abdominal aortic aneurysm, 57 mm in diameter, was admitted to our hospital for endovascular grafting. Preoperative computed tomography and angiography showed friable mural thrombus in the suprarenal and infrarenal aorta, and a diagnosis of shaggy aorta was made. Postoperatively, the patient suffered cerebral infarction, and disseminated intravascular coagulopathy with multiple organ failure developed, resulting in early death on the third day after surgery. An autopsy revealed diffuse atheromatous embolization into the celiac, superior mesenteric, bilateral renal, bilateral hypogastric (trash buttock), and peripheral arteries. This case report serves to demonstrate that an abdominal aortic aneurysm with a shaggy aorta in the proximal neck is a contraindication to endovascular grafting, and that predicting the possibility of diffuse atheromatous embolization by detecting a shaggy aorta is the best way to prevent this catastrophic complication.

Stem cell therapies have been clinically employed to repair the injured heart, and cardiac stem cells are thought to be one of the most potent stem cell candidates. The beating heart is characterized by dynamic mechanical stresses, which may have a significant impact on stem cell therapy. The purpose of this study is to investigate how mechanical stress affects the growth and differentiation of cardiac stem cells and their release of paracrine factors. In this study, human cardiac stem cells were seeded in a silicon chamber and mechanical stress was then induced by cyclic stretch stimulation (60 cycles/min with 120% elongation). Cells grown in non-stretched silicon chambers were used as controls. Our result revealed that mechanical stretching significantly reduced the total number of surviving cells, decreased Ki-67-positive cells, and increased TUNEL-positive cells in the stretched group 24 hrs after stretching, as compared to the control group. Interestingly, mechanical stretching significantly increased the release of the inflammatory cytokines IL-6 and IL-1β as well as the angiogenic growth factors VEGF and bFGF from the cells in 12 hrs. Furthermore, mechanical stretching significantly reduced the percentage of c-kit-positive stem cells, but increased the expressions of cardiac troponin-I and smooth muscle actin in cells 3 days after stretching. Using a traditional stretching model, we demonstrated that mechanical stress suppressed the growth and proliferation of cardiac stem cells, enhanced their release of inflammatory cytokines and angiogenic factors, and improved their myogenic differentiation. The development of this in vitro approach may help elucidate the complex mechanisms of stem cell therapy for heart failure.

Recent studies have shown that the European System for Cardiac Operative Risk Evaluation (Euro-SCORE) is a reliable risk model in cardiac surgery. In Japan, the JapanSCORE has been devised as the Japanese original risk model for cardiovascular surgery. We evaluated the validity of the JapanSCORE, especially in comparison with the logistic EuroSCORE METHODS: We calculated the predicted mortality according to two risk models for 523 consecutive patients who underwent cardiovascular surgery within a 6-year period (July 2003 to June 2009) at Yamaguchi University Hospital. We assessed the scores' validity by calculating the area under the receiver operating characteristics curve (C-index) and by the chi-squared test or Fisher's exact test.The C-indexes were 0.688 with the logistic EuroSCORE and 0.770 with the JapanSCORE (P = 0.053). Although the difference was not significant, the JapanSCORE tended to be more accurate. The C-indexes limited to isolated coronary artery bypass grafting (CABG) were 0.564 with the logistic EuroSCORE and 0.790 with the JapanSCORE (P = 0.001). The Japan-SCORE was significantly more valid than the logistic EuroSCORE for isolated CABG. The actual mortality was 4.0%; the mean predictive mortality was 5.6% with the JapanSCORE and 15.1% with the logistic Euro-SCORE. The mortality predicted by the JapanSCORE was closer to the observed mortality. There was a significant difference between the observed mortality and the logistic EuroSCORE (P0.0001).The JapanSCORE seems to be a more reliable risk model than the logistic EuroSCORE for patients undergoing cardiac or thoracic aortic surgery at Yamaguchi University Hospital.

The surgical treatment for thrombosed type A aortic dissection is controversial. We treated 15 cases (28.8%) with thrombosed type A acute aortic dissection among 52 cases of all type A acute aortic dissection during past 7 years and 8 months. Nine cases was treated conservatively and 6 cases received emergent operation due to cardiac tamponade, shock, and ulcer-like projection (ULP) in the ascending aorta (50 mm). In the group of conservative therapy, 2 cases in which the ascending aorta was enlarged (54, 60 mm), was converted to operation in the acute phase because of further enlargement of ascending aorta and increase of cardiac effusion. The other patients (aortic diameter: 40-46 mm) who received conservative therapy were well controlled by medical therapy in the early and late phase except 1 who died suddenly in the follow-up. There was no mortality and late death in the operated patients. From these results, we conclude that thrombosed type A aortic dissection in which the diameter of ascending aortic aorta is larger than 50 mm, have cardiac tamponade and ULP in the ascending aorta might needs operation.

Bone marrow possesses endothelial progenitor cells that secrete several growth factors and can contribute to the formation of new capillaries. In the present study, we investigated the extent of angiogenesis induced by implantation of autologous bone marrow cells (BMCs) in a rat ischemic hindlimb model and studied whether the increased collateral vessels can improve deteriorated physical function.Ischemic hindlimb was created by ligation of the femoral artery and its branches in Dark Agouti (DA) rats. BMCs (1 x 10(7)) were injected percutaneously at six points into the gastrocnemius muscle. To assess angiogenesis, histologic evaluation and microangiography were performed at 2 weeks postligation. Severity of the ischemic insult was evaluated by measuring blood flow in the adductor and gastrocnemius muscles using nonradioactive colored microspheres and by determining the femoral arteriovenous oxygen difference (AVDO(2)) at 2 weeks postligation. Running time on a motor-driven treadmill was used to represent exercise capacity.The histologic evaluation and microangiogram showed that the implanted BMCs induce angiogenesis. Blood flow to the adductor muscle on the treated side in the bone marrow cell implantation (BMI) group was significantly restored to 77.3 +/- 19.3% of that of the normally perfused limb in comparison to that in control groups (P0.05). AVDO(2) in the BMI group significantly decreased when compared with AVDO(2) in control groups. Rats in the BMI group ran approximately 1.5 times longer than rats in control groups at 2 and 4 weeks postligation (P0.01).Implantation of autologous BMCs induced angiogenesis and improved deteriorated exercise capacity in our rat ischemic hindlimb model.

The purpose of this case report is to determine the unique pathogenesis of a "spared flow tract" through a thick mural thrombus of an aortic aneurysm mimicking the penetrating or dissecting tract of an impending or acute rupture of an abdominal aortic aneurysm (AAA) and to discuss its clinical importance. Three blood flow tracts (i.e., spared flow tracts) penetrating to aortic major branches (inferior mesenteric arteries in two and left renal artery in one) through thick mural thrombi of three aortic aneurysms were found on thin section spiral CT scans. Histopathological examination revealed that the tracts were formed by thrombi and partially covered with endothelial cells. In conclusion, spared flow tracts may be pathways continuing to the aortic major branches through thick mural thrombi of aortic aneurysms and are spared from thrombogenesis because of relatively high blood flows. Their pathogenesis is definitely different from penetrating or dissecting tracts within mural thrombi of ruptured AAAs. Spared flow tracts should not be misinterpreted as penetrating or dissecting tracts of impending or acute rupture.

Management of extensive, chronic, dissecting aortic aneurysms after prior repair of the ascending aorta presents a technical challenge for surgeons. A symptomatic 64-year-old patient was admitted for elective surgical repair of an aortic annular dilatation, causing severe aortic regurgitation, and a Crawford type II extended thoracoabdominal aneurysm, 4 years after he underwent primary repair of an acute aortic dissection. The aorta was diffusely dilated, and there were no sites beyond the distal aortic arch where anastomosis could be performed. We successfully performed total aortic replacement with a 2-stage strategy, using an arch translocation technique and an intra-arch elephant-trunk technique.