NT5E mutation in sisters who underwent aortic valve replacements for aortic stenosis.

Mutations of the NT5E gene encoding the cluster of differentiation 73 (CD73) protein have been found in patients with characteristic calcification of joints and arteries (CALJA). CD73 plays a protective role against aortic valve calcification; therefore, its deletion results in aortic valve calcification. However, to date, there are no reports of a patient with CALJA with aortic stenosis. In this study, we describe 2 extremely rare cases of sisters with identical NT5E gene mutation patterns, both of whom developed late-onset severe aortic stenosis and limb ischaemia. Both patients underwent aortic valve replacement and bilateral distal arterial bypass surgeries successfully. They were genetically diagnosed with CALJA based on the NT5E mutation. Our report suggests that NT5E mutations should be considered in patients requiring aortic valve replacement for a calcified aortic valve and bypass surgery for specific calcified and occluded arteries.

Outcome of thoracoscopic anatomical sublobar resection under 3-dimensional computed tomography simulation.

BACKGROUND: Previous studies have reported the feasibility and efficacy of thoracoscopic anatomical sublobar resection under three-dimensional computed tomography (3DCT) simulation; however, its long-term outcomes have not been clearly established in primary lung cancer. This study aimed to evaluate the long-term outcomes of this technique. METHODS: We retrospectively reviewed data from 112 consecutive patients with selected clinical stage IA non-small cell lung cancer (NSCLC) who underwent thoracoscopic anatomical sublobar resection from 2004 to 2014. This procedure was planned using preoperative 3DCT simulation to ensure sufficient surgical margins and enabled tailor-made surgery for each patient. Patients who had predominantly ground glass opacity lung cancers underwent anatomical sublobar resection as a curative-intent resection. Other patients who were high-risk candidates for lobectomy underwent anatomical sublobar resection as a compromised limited resection. RESULTS: Of the 112 cases, 82 had a curative-intent resection, while 30 had a compromised limited resection. Recurrence occurred in only 2 cases (1.8%), both of which were in the compromised limited group. A second primary lung cancer was observed in 5 cases (4.5%). Of the 5 patients, 4 underwent surgery for a second cancer and had no recurrence. The 5-year overall survival, lung cancer-specific overall survival, and recurrence-free survival rates were 92.5%, 100%, and 98.2%, respectively, for all cases; 97.6%, 100%, and 100%, respectively, in the curative-intent group; and 75.8%, 100% and 92.6%, respectively, in the compromised limited group. CONCLUSIONS: Thoracoscopic anatomical sublobar resection under 3DCT simulation may be an acceptable alternative treatment in selected patients with NSCLC. TRIAL AND CLINICAL REGISTRY: Clinical registration number: IRB No. 2020-98 (Dated: 2020.6.30).

Surgical Treatment for a Super-Giant Right Coronary Artery Aneurysm Induced by Kawasaki Disease.

A 32-year-old man diagnosed with Kawasaki disease at the age of three years presented with coronary artery aneurysm (CAA). The aneurysm increased in size, and the patient was referred to our hospital for surgery. Preoperative computed tomography scan showed a super-giant right CAA and giant left CAAs; surgery was performed. The super-giant right CAA was resected, and the ostium of the right coronary artery was closed; then, coronary artery bypass grafting was performed. The left CAAs were not treated surgically because the risk of rupture was low. Here, we describe the successful surgical treatment of a right super-giant CAA.

Double left brachiocephalic vein in an adult patient who underwent cardiac surgery: a case report.

BACKGROUND: A double left brachiocephalic vein is an extremely rare venous anomaly. CASE PRESENTATION: Herein, we present the case of a 79-year-old woman with a double left brachiocephalic vein who underwent cardiac surgical procedures. The normal left brachiocephalic vein was patent, and the accessory left brachiocephalic vein passed across the heart and aorta in front of the pericardium and drained into the superior vena cava. She underwent surgical ligation of the accessory left brachiocephalic vein, followed by an aortic valve replacement and coronary artery bypass grafting. Her postoperative recovery was uneventful, without any venous complications from the ligation of the accessory vein. The patient is doing well one year after the surgery. CONCLUSIONS: The presence of double left brachiocephalic veins should be recognized before cardiac surgery in order for us to avoid intraoperative technical issues concerning this venous anomaly and unpredictable intraoperative bleeding due to injury of the accessory left brachiocephalic vein.

Surgical Treatment for a Super-Giant Right Coronary Artery Aneurysm Induced by Kawasaki Disease

Abstract A 32-year-old man diagnosed with Kawasaki disease at the age of three years presented with coronary artery aneurysm (CAA). The aneurysm increased in size, and the patient was referred to our hospital for surgery. Preoperative computed tomography scan showed a super-giant right CAA and giant left CAAs; surgery was performed. The super-giant right CAA was resected, and the ostium of the right coronary artery was closed; then, coronary artery bypass grafting was performed. The left CAAs were not treated surgically because the risk of rupture was low. Here, we describe the successful surgical treatment of a right super-giant CAA.

[Surgical Strategy for Aortic Arch Aneurysms in Octogenarians].

BACKGROUNDS: The purpose of this study was to evaluate the short- and mid-term outcomes of open aortic arch surgery and debranching thoracic endovascular aortic repair( TEVAR) in octogenarians. METHODS: Between 2011 and 2019, 26 patients with atherosclerotic aortic arch aneurysms underwent surgery at our institution [open aortic arch surgery( group O):10 patients, debranching TEVAR(group D):16 patients]. RESULTS: There was no operative death in either group. The mean length of hospitalization and intensive care unit stay were 49 and 13 days in group O and 12 and 2 days in group O, respectively. Kaplan-Meier analyses of overall survival (1/6/12/24/36/48 months) showed mortality rates of 100/100/88/88/70/70% in group O and 100/100/87/61/43/26% in group D, respectively. CONCLUSIONS: The acceptable outcomes was demonstrated in octogenarians underwent both open aortic arch surgery and debranching TEVAR. Because of early postoperative recovery, debranching TEVER is considered to be a feasible alternative to conventional open aortic arch surgery in octogenarians.

Aortic remodelling effect of the frozen elephant trunk technique on Stanford type A acute aortic dissection.

Total arch replacement using the frozen elephant trunk procedure is performed for true lumen expansion of the descending aorta in patients with type A acute aortic dissection. However, the remodelling effect of the frozen elephant trunk on the dissected descending aorta is unclear. We aimed to evaluate the effect of the frozen elephant trunk on postoperative descending aortic remodelling after surgery. Between December 2012 and January 2020, we retrospectively investigated 24 patients who underwent total arch replacement using the frozen elephant trunk for type A acute aortic dissection. Remodelling of the descending aorta was evaluated using computed tomography. The aortic remodelling effect, based on aortic true lumen ratio, was determined for (i) DeBakey type (type I versus type III retrograde); (ii) thoracic endovascular aneurysm repair reintervention status (reintervention versus no reintervention); and (iii) stent length of the frozen elephant trunk (60 vs 90 mm). Postoperative true lumen ratio significantly increased in the type I dissection group. The true lumen ratio in the no-reintervention group, which had many patients with the type I dissection, significantly increased after the frozen elephant trunk. Aortic remodelling due to the frozen elephant trunk can be expected after type I acute aortic dissections.

Exacerbation of severe constrictive pericarditis after prior inadequate pericardiectomy.

Pericardiectomy is commonly used to treat constrictive pericarditis (CP); however, persistent calcification can complicate recovery. An 82-year-old man presented with CP following an inadequate pericardiectomy at another hospital two years earlier. He was referred to our hospital with a diagnosis of recurrent CP. Pre-operative computed tomography revealed that the pericardium was not calcified on the anterior of the heart, while the inferior, posterior and lateral surfaces exhibited calcification. Notably, calcification along the inferior portion of the heart formed a calcium envelope structure. Pericardiectomy via re-sternotomy without cardiopulmonary bypass was performed. While dissecting the calcium envelope, a paste-like substance was exuded. Cardiac function improved after pericardiectomy, although the postoperative recovery from heart failure was prolonged. Calcified pericardium should be removed to the extent possible to enhance the efficacy of pericardiectomy, which contributes to improved early surgical results and prevents CP recurrence.

Evaluation of effects of perioperative oral care intervention on hospitalization stay and postoperative infection in patients undergoing lung cancer intervention.

PURPOSE: This retrospective study investigated the effect of perioperative oral care intervention on postoperative outcomes in patients undergoing lung cancer resection, in terms of the length of postoperative hospital stay and the incidence of postoperative respiratory infections. METHODS: In total, 585 patients underwent lung resection for lung cancer, 397 received perioperative oral care intervention, whereas the remaining 188 did not. This study retrospectively investigated the demographic and clinical characteristics (including postoperative complications and postoperative hospital stay) of each group. To determine whether perioperative oral care intervention was independently associated with either postoperative hospital stay or postoperative respiratory infections, multivariate analysis, multiple regression analysis, and multivariate logistic regression analysis were conducted. RESULTS: Parameters significantly associated with a prolonged postoperative hospital stay in lung cancer surgery patients were older age, postoperative complications, increased intraoperative bleeding, more invasive operative approach (e.g., open surgery), and lack of perioperative oral care intervention (standard partial regression coefficient (ß) = 0.083, p = 0.027). Furthermore, older age and longer operative time were significant independent risk factors for the occurrence of postoperative respiratory infections. Lack of perioperative oral care intervention was a potential risk factor for the occurrence of postoperative respiratory infections, although not statistically significant (odds ratio = 2.448, 95% confidence interval = 0.966-6.204, p = 0.059). CONCLUSION: These results highlight the importance of perioperative oral care intervention prior to lung cancer surgery, in order to shorten postoperative hospital stay and reduce the risk of postoperative respiratory infections.

Perioperative presepsin as a potential early predictor for postoperative infectious complications in cardiac surgery.

INTRODUCTION: Postoperative infection remains a serious complication of cardiac surgery; however, no existing biomarkers can detect infection in the early perioperative period. We investigated the usefulness of presepsin, a novel biomarker, in predicting postoperative infectious complications in cardiac surgery with cardiopulmonary bypass. MATERIAL AND METHODS: For patients aged > 18 years who underwent elective cardiac surgery with cardiopulmonary bypass between 2015 and 2017, data of clinical features, perioperative presepsin levels, and infectious complications were collected. We compared the perioperative presepsin levels between the infected and non-infected groups, performed a risk factor analysis for postoperative infection, and calculated the cut-off value of presepsin with postoperative infection. RESULTS: Among the 73 included patients, 20 developed postoperative infectious complications. The presepsin levels pre-operatively and on post-operative day (POD) zero were significantly higher in the infected than in the non-infected group (145.2 vs. 93.2, 514.0 vs. 328.1 [pg mL-1], p < 0.05, respectively). The odds ratio (OR) for postoperative infection included pre-operative presepsin (OR; 1.22 [confidence interval; 1.07-1.40]/10 pg mL-1) and presepsin on POD zero (OR; 1.31 [confidence interval; 1.05-1.64] /100 pg mL-1). The cut-off predictive values for postoperative infectious complications of pre-operative presepsin and on POD zero were 132 and 347 [pg mL-1], respectively. CONCLUSIONS: Perioperative presepsin levels could be an early predictor for postoperative infectious complications in cardiac surgery.

Creating an appropriate access for endovascular repair by replacing a dissected femoral artery in aortic dissection.

Transfemoral endovascular repair has been widely accepted as an effective treatment for type B aortic dissection. However, if the dissection extends to the femoral artery, the transfemoral approach increases the risk of access complications. We describe a case of acute complicated type B aortic dissection involving the dissected bilateral femoral arteries. Successful endovascular repair without access complications was performed through an appropriate access route created by a femoral arterial conduit. We believe that this approach results in reliable cannulation of the true lumen and the reduction of the risk for intimal injury in aortic dissection with the dissected femoral artery.

Hybrid Operation for a Brachiocephalic Aneurysm in a Young Woman With Loeys-Dietz Syndrome.

In the currently evolving field of endovascular surgery, most brachiocephalic aneurysms are treated with stent grafts. Connective tissue disorders are considered a relative contraindication for endovascular repair because of the risk of adverse events at the landing zone in the aorta and its branches, although the surgical grafts from previous repairs could provide stable landing zones. We attempted a new hybrid operative technique for a brachiocephalic aneurysm in a patient with Loeys-Dietz syndrome, who was unsuitable for open surgery because of multiple previous surgeries and possible lung malignancy. The operation was performed by creating an appropriate landing zone using a prosthetic graft followed by endovascular stent grafting, which yielded good results. This hybrid operation is expected to expand the potential for endovascular treatment in patients with connective tissue diseases who are deemed unsuitable for open surgery.

Aortobifemoral Bypass Grafting with Reversed L-Shaped Technique for Endograft Infection.

Endograft infection after abdominal endovascular aortic repair is a rare but catastrophic complication associated with high perioperative mortality and postoperative recurrent infection. The optimal surgical treatment is still controversial, particularly regarding in situ or extra-anatomical revascularization. Herein, we describe a successful surgically treated case of a patient with an endograft infection complicated with abscess formation in the retroperitoneal space around the right common iliac artery. We performed an aortobifemoral bypass grafting using the reversed L-shaped technique by rerouting the right leg of the new prosthesis to avoid the infected area. The patient is doing well 1 year after surgery without recurrent infection. This technique was considered to be advantageous because revascularization could be performed remotely from the infected area.

Right-sided double valve replacement in an adult patient who underwent surgery for pulmonary stenosis in childhood: a case report.

BACKGROUND: Pulmonary regurgitation and the subsequent functional tricuspid regurgitation are frequently observed in adult patients who previously underwent pulmonary valvular operations. Pulmonary valve replacement, in combination with tricuspid annuloplasty, is frequently performed in adult patients. However, postoperative worsening or recurrence of tricuspid regurgitation is a major concern after pulmonary valve replacement with tricuspid annuloplasty. CASE PRESENTATION: Herein, we describe the case of a 56-year-old woman with severe pulmonary regurgitation and functional tricuspid regurgitation after congenital pulmonary stenosis surgery in childhood. Functional tricuspid regurgitation was due to tricuspid annular dilatation, marked right ventricle enlargement, and significant tethering. We performed a bioprosthetic double valve replacement, and the postoperative course was uneventful. The patient is doing well one year after the surgery without prosthetic valve dysfunction. CONCLUSIONS: When functional tricuspid regurgitation is severe and is associated with right ventricular dilatation and subsequent tethering, tricuspid valve replacement rather than annuloplasty should be considered.

Ruptured aneurysm of coronary arteriovenous fistula without aneurysmal coronary artery.

BACKGROUND: Approximately 25% of coronary arteriovenous fistulas present aneurysmal dilatation; however, spontaneous rupture of the aneurysm is rare. Most coronary arteries branching the feeding arteries demonstrate aneurysmal formation, possibly because of shunt flow. CASE REPORT: A 48-year-old woman was referred to our institution for surgical management of ruptured aneurysm of coronary arteriovenous fistula. The aneurysm was located on the left-anterior aspect of the pulmonary artery trunk, communicating with both left and right coronary arteries through two small feeding arteries draining into the pulmonary artery trunk. Both left and right coronary arteries showed normal diameter. The feeding arteries were ligated externally, and fistulous openings were closed within the aneurysm. Postoperative course was uneventful. CONCLUSION: Aneurysm of coronary arteriovenous fistula can occur in patients without aneurysmal coronary artery. Although the association of ruptured aneurysm with coronary fistulas is relatively rare, it should be considered a potential cause of acute cardiac tamponade.

Oxidative stress evaluation of skeletal muscle in ischemia-reperfusion injury using enhanced magnetic resonance imaging.

Acute extremity arterial occlusion requires prompt revascularization. Delayed revascularization induces ischemia-reperfusion injury in the skeletal muscle. Organ injury-induced oxidative stress is widely reported, and oxidative stress is heavily involved in ischemia-reperfusion injury. This study aimed to evaluate oxidative stress in ischemia-reperfusion rat models using 3-carbamoyl PROXYL enhanced magnetic resonance imaging (3-CP enhanced MRI). Ischemia-reperfusion injury was induced through clamping the right femoral artery in rats, with a 4-h ischemia time in all experiments. 3-CP enhanced MRI was performed to evaluate oxidative stress, and the rats were divided into 3 reperfusion time groups: 0.5, 2, and 24 h. Signal intensity was evaluated using 3-CP enhanced MRI and compared in the ischemia-reperfusion and intact limbs in the same rat. Furthermore, the effect of edaravone (radical scavenger) was evaluated in the 4-h ischemia-24-h reperfusion injury rat model. The signal intensity of the ischemia-reperfusion limb was significantly stronger than that of the intact limb, suggesting that oxidative stress was induced in the ischemia-reperfusion muscle. Edaravone administration reduced the oxidative stress in the ischemia-reperfusion limb. The signal intensity of the ischemia-reperfusion limb was stronger than that of the intact limb, presumably reflecting the oxidative stress in the former. 3-CP MRI examination shows promise for effective assessment of oxidative stress and may facilitate early diagnosis of ischemia-reperfusion injury.

The distribution of macrophage subtypes and their relationship to bone morphogenetic protein 2 in calcified aortic valve stenosis.

Activation of the osteogenic signaling cascade (OSC) is thought to be involved in aortic valve stenosis. The aim of this study was to clarify the distribution of macrophage (M) subtypes in the calcified aortic valve and to clarify the relationship between osteoblast-like cells (OLC) and OSC activation. Thirty-six cases of calcified aortic valve were set as the calcification group, and six autopsy cases of aortic valve without pathological calcification comprised the noncalcification group. Aortic valve tissues were used in histological studies including single and double immunostaining to identify M subtypes, bone morphogenetic protein 2 (BMP2) and osteopontin, reverse transcription polymerase chain reaction (RT-PCR) for CD206, heme oxygenase-1 (HO-1), and BMP2 mRNAs and in situ RT-PCR for BMP2 mRNA. Ms positive for CD68, CD163, CD206, and HO-1 were significantly higher in the calcification group than in the noncalcification group (P < 0.01). Comparison of the positive cells in each section of the calcification group showed that cells of all M subtypes were found around calcifications. Osteopontin+ cells were also observed around calcifications. CD163+/CD206+ M2 and CD163+/HO-1+ Mox were significantly higher in the sponge layer in both groups. In double immunofluorescence, CD206+ and a portion of HO-1+ Ms expressed BMP2, and in RT-PCR, CD206 or HO-1 mRNA was expressed in cases in which BMP2 was expressed. In in situ RT-PCR, expression of BMP2 mRNA was observed around calcifications. This work clarifies the distribution of M subtypes in calcified aortic valves. In addition, the results suggest that CD206+ M2 and HO-1+ Mox, which express BMP2 in calcified aortic valves, are OLC candidates.

NT5E Genetic Mutation Is a Rare But Important Cause of Intermittent Claudication and Chronic Limb-Threatening Ischemia.

BACKGROUND: NT5Egenetic mutations are known to result in calcification of joints and arteries (CALJA), and worldwide, 14 patients from 7 families have been reported.Methods and Results:A total of 5 patients from 2 independent families with CALJA were found in Japan. Of them, 3 complained of intermittent claudication (IC), and 1 suffered from bilateral chronic limb-threatening ischemia (CLTI). Whole-exome sequencing analysis revealed an identical mutation pattern (c.G3C on the exon 1 start codon) that was unique compared withNT5Emutations reported in other countries. CONCLUSIONS: Vascular specialists need to recognize CALJA as a rare cause of ischemic IC and CLTI.

Bare stent removal in open thoraco-abdominal aortic repair after endovascular treatment with the PETTICOAT technique.

The Provisional Extension to Induce Complete Attachment (PETTICOAT) technique using distal bare stents can enhance the effect of proximal thoracic endovascular aortic repair. Here, we present the case of a patient who underwent open surgical conversion and bare stent removal due to progressive thoraco-abdominal aortic enlargement. Previously placed bare-metal stents were embedded deeply in the aortic wall. After explantation of the bare stents, reno-visceral arterial orifices became fragile due to considerable intimal defects, and special care was necessary to make buttons and subsequent separate branch graft anastomoses. As bare stent removal makes open surgical conversion technically difficult, the indication for the PETTICOAT technique should be considered.

Internal thoracic artery pseudoaneurysm after redo aortic root replacement.

Pseudoaneurysm of the internal thoracic artery (ITA) or bleeding from the ITA is an extremely rare complication after cardiovascular surgery via a median sternotomy. Early treatment is needed in the case of massive haemorrhage or a rapidly enlarging pseudoaneurysm. Herein, we present a rare case of a delayed large pseudoaneurysm of the right ITA in a 49-year-old woman with Marfan syndrome who underwent redo aortic root replacement via re-median sternotomy and pacemaker implantation. Diagnostic selective angiography revealed the origin of the pseudoaneurysm, and simultaneous transcatheter embolisation of the ITA was successfully performed. Follow-up computed tomography imaging showed no evidence of contrast media extravasation from the ITA and recurrent extra-pleural haemorrhage. Our findings suggest that postoperative management of patients who have undergone median sternotomy, including cardiovascular surgeries, should also focus on the prevention or early detection of pseudoaneurysm of the ITA to avoid life-threatening conditions.