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A 73-year-old woman with Valsalva aneurysm and mitral regurgitation was introduced to our department. We performed combined operation including aortic root partial repair and mitral valve repair. After wenning from cardiopulmonary bypass, intraoperative aortic dissection was confirmed by transesophageal echocardiography from the ascending aorta to the descending aorta, entry was near to proximal anastomosis line of the ascending aorta. To avoid heart failure, the ascending aorta wrapping by prothesis graft was performed to protect from urgent rupture postoperative at first stage. According to contrast computed tomography (CT) findings, location of entry was correspond with aortic clamping. We performed partial aortic replacement including innominate artery reconstruction for her at fourth day postoperative for treating aortic dissection at second stage. Postoperative course was uneventful.

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.

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

Objective: This study aimed to clarify the selection and determination of appropriate treatment for acute symptomatic spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). Methods: Data from 10 consecutive patients, who were diagnosed with symptomatic SIDSMA using computed tomography angiography and were managed in our hospital from January 2010 to October 2015, were retrospectively collected and analyzed. Results: There were nine males and one female; mean patient age was 50.3 (range, 35–64) years. All patients experienced acute abdominal pain, and three patients experienced concomitant vomiting. Only one patient exhibited symptoms of suspected peritonitis and intestinal ischemia. Three patients showed improved abdominal pain before admission to our hospital. One patient experienced severe abdominal pain that could not be managed using morphine; he underwent right external iliac to superior mesenteric artery bypass with a great saphenous vein graft. No patient presented with intestinal necrosis. All patients survived, and no patient developed complications during the follow-up period of up to 42 (24.5±16.5) months. Conclusion: Conservative management appears to be the most feasible treatment for SIDSMA. However, open surgery can be performed in patients presenting with any symptoms of intestinal ischemia.

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.

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.

Coral reef Aortic Syndrome can result in significant visceral and lower limb ischemia. We present a 72-year-old male with postprandial abdominal pain and intermittent claudication. Computed tomography demonstrated a calcified plaque occluding the thoracoabdominal aorta. Additionally, the celiac axis was stenotic, and the superior mesenteric artery was completely occluded. The origin of the inferior mesenteric artery was aneurysmal. Aortic rerouting from the ascending to the infrarenal aorta was performed. The superior mesenteric artery was reconstructed with a saphenous vein, and the inferior mesenteric artery was divided and anastomosed directly to the aortic bypass. The procedure resulted in complete relief from the ischemic symptoms.

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.

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.

Highlights • Spontaneous regression of anterior mediastinal seminoma with normalization of β-human chorionic gonadotropin (β-hCG) levels shows good clinical outcome and sensitive to chemotherapy. • Video-assisted thoracic surgery (VATS) is effective solution for definite diagnosis of anterior mediastinal. • Apoptosis may be a reason of tumors’ spontaneous regression., Introduction Although spontaneous regression (SR) of anterior mediastinal seminoma is very rare with normalization of β-human chorionic gonadotropin (β-hCG) level, video-assisted thoracic surgery (VATS) is the most effective solution for definite diagnosis of indeterminate anterior mediastinal masses. Diagnosis, therapeutic interventions, and outcomes A rare case of an asymptomatic 37-year-old man with an anterior mediastinal mass that was detected on a routine chest X-ray is presented. Computed tomography (CT) showed a large anterior mediastinal tumor with superior vena cava invasion and SR before VATS for definitive diagnosis. On pathology, the definitive diagnosis was seminoma. Microscopic examination showed abundant apoptotic cells within the tumor. Chemotherapy (bleomycin 30 mg/day, etoposide 200 mg/day, cisplatin 40 mg/day) was given to this patient, and the tumor showed high sensitivity. Conclusion Anterior mediastinal seminoma showing SR induced by spontaneous apoptosis of tumor cells may have good sensitivity to chemotherapy, and a good clinical outcome may be achieved in these patients. This case also highlights that VATS is the most effective solution for definite diagnosis of indeterminate anterior mediastinal masses.

Although various osteogenic inducers contribute to the calcification of human aortic valve interstitial cells, the cellular origin of calcification remains unclear. We immunohistochemically investigated the cellular origin of valve calcification using enzymatically isolated cells from both calcified and non-calcified human aortic valve specimens. CD73-, 90-, and 105-positive and CD45-negative mesenchymal stem-like cells (MSLCs) were isolated from both types of valve specimens using fluorescence-activated cell sorting. MSLCs were further sorted into CD34-negative and -positive cells. Compared with CD34-positive cells, CD34-negative MSLCs were significantly more sensitive to high inorganic phosphate (3.2 mM), calcifying easily in response. Furthermore, immunohistochemical staining showed that significantly higher numbers (~7-9-fold) of CD34-negative compared with CD34-positive MSLCs were localized in calcified aortic valve specimens obtained from calcified aortic stenosis patients. These results suggest that CD34-negative MSLCs are responsible for calcification of the aortic valve.

Although aging is well established as an important risk factor for aortic stenosis, the mechanism of age-related aortic valve calcification is yet unknown. Here, we investigated this mechanism in tissue and cellular levels using middle-aged rats. Aortic valve specimens were obtained by dissecting from 9-week-old (young) and 30-week-old (aged) male Wistar rats. In the aged rats, the main risk factors for aortic stenosis in plasma were still in the normal range; however, their number of calcified specimens was significantly increased in comparison with the young rats. Aortic valve interstitial cells (AVICs) obtained from explants of aortic valve specimens were cultured for 14 days after reaching confluence. Spontaneous calcification, the expressions of calcigenic genes, that is, BMP-2, alkaline phosphatase (ALP), and osterix (osteogenic transcription factor) and ALP enzyme activity in AVICs from aged rats were enhanced in comparison with those from young rats. However, neither typical calcification inducing reagents (dexamethasone, β-glycerophosphate, and high concentration of phosphate) nor tumor necrosis factor-α (an inflammatory cytokine) accelerated the spontaneous calcification of AVICs from aged rats. These results suggest that aortic valve calcification progresses with age partly through an activation of the BMP-2 pathway. Keywords:: calcification, aortic valve, BMP-2, aging

A 71-year-old man underwent total arch replacement for the true aortic arch aneurysm. On the post-operative day (POD) 10, right hemiplegia and motor aphasia occurred, and it was revealed that there were multiple cerebral infarction in brain computer tomography scan and magnetic resonanse imaging. Furthermore, platelet count has declined significantly from POD 15, so we suspected that heparin-induced thrombocytopenia might occurred. Then, we stopped continuous injection of heparin and administered argatroban and warfarin. In blood examinations, anti-platelet factor 4(PF4)/ heparin antibody measured by latex turbidimetry significantly increased at 5.2 U/ml, and specific immunoglobulin G for PF4/ heparin was also significantly high( optical density 2.334, cut off 0.400). Measurement of platelet derived microparticles produced by stimulation using various dose of heparin( functional assay) indicated typical pattern observed in heparin-induced thrombocytopenia. Thereafter, platelet count recovered and the patient recovered without another thromboembolic event.

We report a case of simultaneous repair of an extensive thoracic aortic aneurysm from the aortic root to the distal aortic arch. A 54-year-old male had annuloaortic ectasia and a transverse aortic and distal arch aneurysm. Aneurysms of the descending aorta and the abdominal aorta were also demonstrated. The patient underwent aortic valve-sparing root reconstruction, replacement of the aortic arch and placement of a frozen elephant trunk stent-graft concomitantly through a median sternotomy incision. Because a complicated procedure was necessary, root reconstruction was performed first and coronary perfusion was resumed. This case suggests that the surgical procedure should be determined on the bases of the situation of thoracic aortic aneurysm and the general condition of the patient. Treatment for extensive diseased aorta from the aortic root to the distal aortic arch is a surgical challenge. Although single-stage repair is one of the options for this condition, it is very invasive. Total arch replacement with the frozen elephant trunk technique is efficacious to exclude distal arch aneurysm or descending aortic aneurysm through median sternotomy. An aortic valve-sparing operation was developed to preserve the native aortic valve function in order to improve the patient's quality of life. We herein report a case of concomitant total arch replacement using a frozen elephant trunk and aortic valve-sparing operation for extensive thoracic aortic aneurysm.

Calcific aortic valve stenosis (CAS) is the most frequent heart valve disease in the elderly, accompanied by valve calcification. Tumor necrosis factor-α (TNF-α), a pleiotropic cytokine secreted mainly from macrophages, has been detected in human calcified valves. However, the role of TNF-α in valve calcification remains unclear. To clarify whether TNF-α accelerates the calcification of aortic valves, we investigated the effect of TNF-α on human aortic valve interstitial cells (HAVICs) obtained from patients with CAS (CAS group) and with aortic regurgitation or aortic dissection having a noncalcified aortic valve (control group). HAVICs (2 × 10(4)) were cultured in a 12-well dish in Dulbecco's modified Eagle's medium with 10% fetal bovine serum. The medium containing TNF-α (30 ng/ml) was replenished every 3 days after the cells reached confluence. TNF-α significantly accelerated the calcification and alkaline phosphatase (ALP) activity of HAVICs from CAS but not the control group after 12 days of culture. Furthermore, gene expression of calcigenic markers, ALP, bone morphogenetic protein 2 (BMP2), and distal-less homeobox 5 (Dlx5) were significantly increased after 6 days of TNF-α treatment in the CAS group but not the control group. Dorsomorphin, an inhibitor of mothers against decapentaplegic homologs (Smads) 1/5/8 phosphorylation, significantly inhibited the enhancement of TNF-α-induced calcification, ALP activity, Smad phosphorylation, and Dlx5 gene expression of HAVICs from the CAS group. These results suggest that HAVICs from the CAS group have greater sensitivity to TNF-α, which accelerates the calcification of aortic valves via the BMP2-Dlx5 pathway.