Impact of valvuloarterial impedance on left ventricular reverse remodeling after aortic valve neocuspidization.

BACKGROUND: Aortic valve neocuspidization (AVNeo) has emerged as a promising aortic valve procedure, and is expected to have a larger effective orifice area (EOA) than commercially available bioprostheses. It is, however, unclear which indices could facilitate left ventricular (LV) reverse remodeling after AVNeo. The aim of this study is to verify the impact of global left ventricular afterload on the LV reverse remodeling following AVNeo. METHODS: Data-available consecutive 38 patients (median age, 77; interquartile range, 72.8-82.0) undergoing AVNeo for severe aortic stenosis were enrolled in this study. Preoperative and the last follow-up echocardiographic data were retrospectively analyzed including the valvuloarterial impedance (Zva), a marker of global LV afterload. Reduction in LV geometry index (LVGI) and relative wall thickness (RWT) were used as an indicator for LV reverse remodeling. RESULTS: The Zva reduced in 24 patients (63.2%) during the follow-up period (median, 12 months). Reduction in Zva significantly correlated to improvement of LV geometry (LVGI (r = 0.400, p = 0.013) and RWT (r = 0.627, p < 0.001)), whereas increase in EOA index did not significantly correlate to LVGI (r = 0.009, p = 0.957), or RWT (r = 0.105, p = 0.529)). The reduction in Zva was the multivariate predictor of LV reverse remodeling. CONCLUSIONS: Low global LV afterload led to significant LV reverse remodeling even after AVNeo, which could achieve better valve performance than the conventional bioprostheses.

Clinical Results 5 Years after Great Saphenous Vein Stripping.

Background: As a standard treatment for the varicose vein of the great saphenous vein (GSV) type, endovenous ablation (EVA) is the main approach. However, as a background to this, in Europe and the United States, neovascularization (Neo) following high ligation (HL) of the saphenofemoral junction (SFJ) at the time of GSV stripping has been emphasized as one of the reasons for the high rate of recurrence. However, in Japan, almost no similar mid- or long-term results of GSV stripping have been reported. Patients and Methods: From September 2011 to March 2014 when EVA was not my surgical option, 413 consecutive legs of patients underwent GSV stripping by myself using the same procedure. The patients were contacted by phone 5 years later, and recurrent varices after surgery (REVAS) and reoperation (REDO) were investigated. A total of 270 legs of the 391 living cases (69%) underwent venous ultrasonography (VUS). HL of the SFJ was performed via central flash ligation with towing and pulling out of the peripheral side branches containing the accessory saphenous veins. In principle, GSV stripping was performed using the invagination method in the range of the entire reflux region from the HL cut section to the confluent section of the side branch causing branch varicose veins. The range of stripping was to the upper thigh in 3 legs, to the middle thigh in 3 legs, to the lower thigh in 7 legs, to the knee in 46 legs, to the upper calve in 83 legs, to the middle calve in 52 legs, and over the full length in 76 legs. Stab avulsion was performed as much as possible for the side-branch varices. On VUS, the SFJ's stump of GSV, the presence of side-branch remnants and their reflux, the presence or absence of Neo, and the recurrent lesions in other sites were evaluated. REVAS were classified as follows: Level 1, symptomatic recurrent lesion for which surgery is indicated; Level 2, asymptomatic recurrent lesion possibly requiring future surgery; and Level 3, asymptomatic recurrent lesion that is unlikely to require future surgery. Results: Of the 391 legs of patients who could be contacted, REDO was performed in 23 (6%), including 15 limbs, immediately after this investigation, and symptomatic REVAS were observed in 29 (7%). In 270 legs examined by VUS, REVAS were diagnosed as follows: 29 legs with Level 1 lesion, 40 legs with Level 2 lesion, and 27 legs with Level 3 lesion. Level 1 REVAS that occurred at the SFJ were observed only in 3 legs (1.1%), Level 1 REVAS due to incompetent perforating veins (IPVs) were observed in 14 legs (5%), and Level 1 solitary tributary varices were observed in 9 legs (3%). Conclusion: In this study, REVAS at the SFJ were significantly less than those in the past reports. It has been shown that REVAS due to IPVs or solitary tributary varices were more important than those at the SFJ. (This is a translation of Jpn J Phlebol 2019; 30(3): 259-265.).

[Lung Cancer Diagnosed as Primary Site Two Years after the Resection of the Thoracic Wall Cancer of Unknown Primary].

A 73-year-old man was referred to our department because of the left chest wall tumor. Computed tomography(CT) showed a chest wall tumor. The chest wall resection was carried out and the tumor was diagnosed as metastatic squamous cell carcinoma of unknown primary. The elevated serum level of carcinoembryonic antigen (CEA) was normalized after the surgery. Two years after the resection, the serum level of CEA elevated again and CT showed the pulmonary tumor 20 mm in diameter in the left upper lobe adjoining to the mediastinal pleura. The partial resection of the left upper lobe with mediastinal pleura was carried out. Pathological examination revealed this tumor to be the primary site of the previously resected chest wall tumor.

Three-year Survival Rate after Radiofrequency Ablation for Surgically Resectable Colorectal Lung Metastases: A Prospective Multicenter Study.

Background Although radiofrequency ablation (RFA) is widely performed for the treatment of colorectal cancer (CRC) lung metastases, its efficacy for candidates with surgically resectable disease is unclear. Purpose To evaluate the prognosis after RFA in participants with resectable CRC lung metastases. Materials and Methods For this prospective multicenter study (ClinicalTrials.gov identifier: NCT00776399), participants with five or fewer surgically resectable lung metastases measuring 3 cm or less were included. Participants with CRC and a total of 100 lung metastases measuring 0.4-2.8 cm (mean, 1.0 cm ± 0.5) were chosen and treated with 88 sessions of RFA from January 2008 to April 2014. The primary end point was the 3-year overall survival (OS) rate, with an expected rate of 55%. The local tumor progression rate and safety were evaluated as secondary end points. The OS rates were generated by using the Kaplan-Meier method. Log-rank tests and Cox proportional regression models were used to identify the prognostic factors by means of univariable and multivariable analyses. Adverse events were evaluated according to the Common Terminology Criteria for Adverse Events, version 3.0. Results Seventy participants with CRC (mean age, 66 years ± 10; 49 men) were evaluated. The 3-year OS rate was 84% (59 of 70 participants; 95% confidence interval [CI]: 76%, 93%). In multivariable analysis, factors associated with worse OS included rectal rather than colon location (hazard ratio [HR] = 7.7; 95% CI: 2.6, 22.6; P < .001), positive carcinoembryonic antigen (HR = 5.8; 95% CI: 2.0, 16.9; P = .001), and absence of previous chemotherapy (HR = 9.8; 95% CI: 2.5, 38.0; P < .001). Local tumor progression was found in six of the 70 participants (9%). A grade 5 adverse event was seen in one of the 88 RFA sessions (1%), and grade 2 adverse events were seen in 18 (20%). Conclusion Lung radiofrequency ablation provided a favorable 3-year overall survival rate of 84% for resectable colorectal lung metastases measuring 3 cm or smaller. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Gemmete in this issue.

[Ethanol Instillation for Mediastinal Cyst].

Mediastinal cyst rarely becomes symptomatic due to compression of adjacent organs. In such case, treatment has to be considered. Either surgical extirpation or percutaneous decompression is the treatment of choice. A 53 years old woman who had been diagnosed with intractable epilepsy, mental retardation and Chilaiditi syndrome was admitted to our hospital because of dyspnea and difficulty in conversation. Chest computed tomography (CT) revealed a mediastinal cystic lesion which expanded to the right chest cavity and occupied most of the right chest cavity. That cyst was treated by percutaneous aspiration and ethanol instillation successfully. Ethanol instillation for the symptomatic mediastinal cyst is the treatment of choice in case the surgery is not feasible.

[Effectiveness of perioperative administration of eltrombopag in a patient with idiopathic thrombocytopenic purpura undergoing cardiovascular surgery].

We report a case of chronic aortic dissection and angina pectoris with idiopathic thrombocytopenic purpura treated perioperatively with eltrombopag. A 72-year-old man was admitted to our hospital because of significant enlargement of an ulcer-like projection in the thoracic aorta revealed by chest computed tomography after acute aortic dissection. Laboratory data showed thrombocytopenia with idiopathic thrombocytopenic purpura. Eltrombopag was administered 12.5 mg daily and increased by 12.5 mg every 2 weeks until 37.5 mg/day to control idiopathic thrombocytopenic purpura(ITP). After 7 weeks' eltrombopag therapy, thrombocyte increased, and the patient underwent total arch replacement. Nine months later, coronary angiography revealed progression of coronary artery stenosis at the left main trunk. The patient underwent off-pump coronary artery bypass grafting 10 days after initiation of eltrombopag therapy. His postoperative course was uneventful. Eltrombopag was suggested to be effective in perioperative management in a patient with idiopathic thrombocytopenic purpura undergoing cardiovascular surgery.

Subfascial endoscopic perforator surgery for posterolateral perforators performed in the prone position.

OBJECTIVES: Subfascial endoscopic perforator surgery (SEPS) is usually performed for posteromedial perforators in the supine position, but subfascial endoscopic perforator surgery for posterolateral perforators in the prone position has not been reported. METHODS: A 51-year-old male suffered from a venous stasis ulcer around his lateral malleolus because of reflux in the small saphenous vein and incompetent perforating veins around the ulcer. RESULTS: Stripping of the small saphenous vein and subfascial endoscopic perforator surgery utilizing screw-type ports was successfully conducted in the prone position. CONCLUSIONS: The prone position enables interruption of the posterolateral perforators, because gravity-dependent flattening of the muscles enables creation of sufficient subfascial space.

[Successful resection of lung cancer with idiopathic pulmonary fibrosis treated by pirfenidone during perioperative period].

We report a case of lung cancer treated with pirfenidone as preoperative therapy before subsequent successful surgical resection. A 76-year-old man was admitted to our hospital because of abnormal shadows and diffuse reticular shadow in bilateral lung on chest computed tomography(CT). CT-guided percutaneous lung biopsy confirmed suquamous cell carcinoma for both lung. Pulmonary reticular shadow was diagnosed as idiopathic pulmonary fibrosis (IPF) clinically and the pirfenidone was administered 600 mg daily and increased by 600 mg for every week until 1,800 mg/day to control IPF. After 3 weeks pirfenidone therapy, Krebs von den Lungen( KL)-6, pulmonary surfactant( SP)-D and lactate dehydrogenase (LDH) decreased, and the patient underwent wedge resection. His postoperative course was uneventful.

[Lung cancer occurring in a left upper division which is mirror imaged to a right upper lobe].

A 55-year-old man was admitted to our hospital because of an abnormal shadow in the left upper division on chest computed tomography(CT). Virtual bronchoscopy revealed a displaced anomalous bronchus. Thin sliced CT revealed complete lobulation between the upper division and the lingula. Three dimensional (3D)-CT revealed abnormal distribution of the left pulmonary artery which descended without passing over the left main bronchus. The left upper division was evaluated to be mirror imaged to a right upper lobe. Video assisted thoracoscopic left upper divisionectomy was performed. The tumor was diagnosed as adenocarcinoma( pT1aN0M0:p-stage I A).

Subfascial endoscopic perforator surgery using screw-type ports is a very useful component of a comprehensive treatment program for chronic venous insufficiency.

BACKGROUND: Subfascial endoscopic perforator surgery (SEPS) with a two-port system utilizing screw-type ports, CO2 insufflation and an ultrasonic coagulation system, is a useful procedure that does not require burdensome apparatus and techniques. SEPS was accepted as a national advanced medical system by the Japanese Ministry of Health, Labor and Welfare in May 2009. PATIENTS AND METHODS: Forty-one limbs of 35 patients with 10 active ulcers (C6) and 2 healed ulcers (C5) were treated by SEPS between February 2010 and December 2011. Thirty-three limbs had concomitant superficial vein surgery. SEPS alone was performed on 8 limbs, in 6 of which the superficial veins had already been ablated. In 2 limbs, incompetent perforating veins (IPVs) existed under the affected skin, around the scars of past surgery. RESULTS: All stasis ulcers of the 10 C6 limbs healed between 1 week and 14 months after SEPS (mean 2.9 months), with no ulcer recurrence during the follow-up period (2 to 24 months). IPVs under the scars were easily and safely interrupted by SEPS. CONCLUSION: SEPS is a very useful component of a comprehensive treatment program for chronic venous insufficiency, especially in patients with venous stasis ulcers and IPVs under the scars of past surgery.

Bronchopulmonary foregut malformation.

Bronchopulmonary foregut malformation (BPFM) is a rare anomaly of accessory pulmonary tissue that usually arises from esophagus or stomach. We present a case of extralobar pulmonary sequestration (ELS) connecting with the esophagus by a cyst, the inner wall of which is lined with squamous epithelium or respiratory epithelium. BPFM is sometimes used to group a number of ventral anomalies of accessory pulmonary tissue. The term currently refers specifically to those lesions composed of sequestrations that retain communication with the gastrointestinal tract. Usually the communication is a well-formed muscular tube lined with stratified squamous or columnar epithelium. The presence of both epithelia in a communication that is a component of the BPFM suggests embryogenesis. We describe an adult with BPFM composed of ELS and a connecting stalk to the esophagus by a foregut cyst that contains both squamous epithelium and respiratory epithelium.

[Cavernous hemangioma of the superior mediastinum; report of a case].

A 44-year-old female was admitted with an abnormal left mediastinal shadow on chest roentgenography. Computed tomography (CT) revealed a mass lesion in the left superior mediastinum, which was not enhanced with contrast medium. Magnetic resonance imaging demonstrated equal signal intensity to that of the muscle on T1 weighted images, and higher signal intensity on T2 weighted images. As a cystic mediastinal tumor was suspected preoperatively, thoracoscopic excision was performed. The tumor was diagnosed as a cavernous hemangioma by pathology. A preoperative diagnosis is difficult because of a variable feature of image study. When the diagnosis of the cystic tumor of mediastinum is made, the diagnosis of mediastinal hemangioma should be kept in mind.

Real-time nanomicroscopy via three-dimensional single-particle tracking.

We developed a new method for real-time, three-dimensional tracking of fluorescent particles. The instrument is based on a laser-scanning confocal microscope where the focus of the laser beam is scanned or orbited around the particle. Two confocal pinholes are used to simultaneously monitor regions immediately above and below the particle and a feedback loop is used to keep the orbit centered on the particle. For moderate count rates, this system can track particles with 15 nm spatial resolution in the lateral dimensions and 50 nm in the axial dimension at a temporal resolution of 32 ms. To investigate the interaction of the tracked particles with cellular components, we have combined our orbital tracking microscope with a dual-color, wide-field setup. Dual-color fluorescence wide-field images are recorded simultaneously in the same image plane as the particle being tracked. The functionality of the system was demonstrated by tracking fluorescent-labeled artificial viruses in tubulin-eGFP expressing HUH7 cells. The resulting trajectories can be used to investigate the microtubule network with super resolution.

Simultaneous transport of different localized mRNA species revealed by live-cell imaging.

Intracellular mRNA localization is a common mechanism to achieve asymmetric distributions of proteins. Previous studies have revealed that in a number of cell types, different mRNA species are localized by the same transport machinery. However, it has been unclear if these individual mRNA species are specifically sorted into separate or common ribonucleoprotein (RNP) particles before or during transport. Using budding yeast as a model system, we analyzed the intracellular movement of individual pairs of localized mRNA in live cells. Yeast cells localize more than 20 different mRNAs to the bud with the help of the Myo4p/She3p/She2p protein complex. For live cell imaging, mRNA pairs were tagged with tandem repeats of either bacteriophage MS2 or lambda boxB RNA sequences and fluorescently labeled by fusion protein constructs that bind to the RNA tag sequences. Using three-dimensional, single-particle tracking with dual-color detection, we have tracked the transport of two different localized mRNA species in real time. Our observations show that different localized mRNAs are coassembled into common RNP particles and cotransported in a directional manner to the target site. Nonlocalized mRNAs or mutant mRNAs that lack functional localization signals form separate particles that are not transported to the bud. This study reveals a high degree of co-ordination of mRNA trafficking in budding yeast.

Intravalvular implantation technique for a modified Bentall's procedure in aortitis syndrome.

Surgical treatments of aortic root involvement in aortitis syndrome are frequently complicated by valve detachment and pseudoaneurysmal formation during active inflammation. A 40-year-old woman with aortitis syndrome complicating the ascending aortic aneurysm, severe aortic regurgitation (AR), and left coronary ostial stenosis was successfully treated by aortic root replacement and concomitant coronary artery bypass grafting (CABG) during acute inflammation. We devised an intravalvular implantation between the fragile aortic annulus and Teflon felt to a modified Bentall's procedure, which prevented anastomotic leakage and pseudoaneurysmal formation in the late period.