[Subclavian-aortic Bypass for Management of Aortic Coarctation in Adults:Report of a Case].

A 57-year-old man presented to the hospital with dyspnea. A diagnosis of hypertensive heart failure was made, and treatment was initiated. However, his ankle-brachial index had decreased to 0.61 on the right and 0.56 on the left side, and he had intermittent claudication with decreased renal function( serum creatinine, 1.73 mg/dl). Thoracoabdominal contrast-enhanced computed tomography showed severe stenosis with a diameter of 2.2 mm in the distal arch and marked development of collateral vessels, and a diagnosis of aortic stenosis was made. Vascular catheterization revealed a pressure gradient of 60 mmHg between the upper and lower extremities. We performed a left-sided open thoracotomy and left subclavian-descending aortic bypass( 16 mm J Graft, Shield). The patient recovered without postoperative complications, and the pressure gradient between the upper and lower extremities eventually decreased to 6 mmHg.

Pulmonary valve myxoma requiring pulmonary valve replacement: a case report.

BACKGROUND: Most cardiac myxomas occur in the atria. Myxomas arising from the heart valves are rare, and there are only a few reports of myxomas arising from the pulmonary valve. Complete resection and prevention of embolization at the time of the first surgery are important to prevent the recurrence of myxomas. CASE PRESENTATION: An 82-year-old female was scheduled to undergo surgery for a fracture of the right femoral neck. The preoperative echocardiography showed a mass in the right ventricular outflow tract. The mass was 36 × 30 mm in size and entered into the pulmonary artery during systole. Cardiac synchronous computed tomography showed a stalked bifurcated mass near the pulmonary valve, which was suspected to be a myxoma. Surgical findings showed a lumen-occupying tumor when the main pulmonary artery was incised. Since the tumor was a single mass with a stalk on the pulmonary valve (right and left pulmonary valve cusps), tumor resection and pulmonary valve replacement (bioprosthetic valve) were performed. A right prosthetic femoral head insertion was performed on postoperative day 36, and the patient was transferred to the hospital on postoperative day 44. However, 1 year later, the patient developed a large myxoma (recurrence) that completely occluded the right pulmonary artery and died of right heart failure. CONCLUSIONS: We report the case of a patient with a very rare myxoma arising from the pulmonary valve, which was treated with tumor resection and pulmonary valve replacement surgery; however, the patient developed another myxoma 12 months later and this tumor was larger than the primary tumor. The surgical margins were indistinct, and there was a high possibility of residual tumor in the pulmonary artery wall; hence, an extended resection should have been considered. The recurrence of myxoma, in this case, suggests that it is important to completely resect the primary tumor during the first surgery and to prevent intraoperative embolization.

Intratumoral gene expression of dihydrofolate reductase and folylpoly-c-glutamate synthetase affects the sensitivity to 5-fluorouracil in non-small cell lung cancer.

BACKGROUND: Various factors related to the sensitivity of non-small cell lung carcinoma (NSCLC) to 5-fluorouracil (5-FU) have been reported, and some of them have been clinically applied. In this single-institutional prospective analysis, the mRNA expression level of five folic acid-associated enzymes was evaluated in surgical specimens of NSCLC. We investigated the correlation between the antitumor effect of 5-FU in NSCLC using an anticancer drug sensitivity test and the gene expression levels of five enzymes. MATERIALS AND METHODS: Forty patients who underwent surgery for NSCLC were enrolled, and the antitumor effect was measured using an in vitro anticancer drug sensitivity test (histoculture drug response assay) using freshly resected specimens. In the same sample, the mRNA expression levels of five enzymes involved in the sensitivity to 5-FU were measured in the tumor using real-time PCR. The expression levels and the result of the sensitivity test were compared. RESULTS: No correlation was found between dihydropyrimidine dehydrogenase (DPD), orotate phosphoribosyltransferase (OPRT), or DPD/OPRT expression and the antitumor effects of 5-FU. On the other hand, a correlation was found between thymidylate synthase (TS), folylpoly-c-glutamate synthetase (FPGS), and dihydrofolate reductase (DHFR) expression and 5-FU sensitivity. CONCLUSION: Expression of FPGS and DHFR may be useful for predicting the efficacy of 5-FU-based chemotherapy for NSCLC.

[A case of asymptomatic Stanford type A aortic dissection with multiple perforator infarcts due to pseudointracavitary thrombus].

A 56-year-old man presented to our hospital as he presented progressive hemiplegia of the right upper limb with no other symptoms, including chest pain. Inter-arm blood pressure difference was not observed. Laboratory investigations revealed an elevated D-dimer value (2.4 µg/ml). Chest X-ray study showed normal findings without widened mediastinum. Brain MRI showed acute multiple brain infarcts in the left posterior limb of the internal capsule and right pons on diffusion-weighted imaging. Bilateral internal carotid arteries were non-occlusive in MRA. Carotid duplex ultrasonography revealed normal internal carotid artery flow velocities bilaterally. Because ischemic lesions were found in multiple vascular territories, and D-dimer value was elevated, the patient underwent thoracic contrast-enhanced-CT to exclude malignant tumors. Stanford type A aortic dissection limited to the ascending aorta was detected. As the plaque had accumulated in the false lumen, we suspected that plaque in the false lumen could be an embolic source. After ascending aortic replacement surgery, brain infarction did not recur during hospitalization. In cases of ischemic stroke wherein multiple vascular territories are detected, and D-dimer value is elevated, even in patients without chest pain, the possibility of painless Stanford type A aortic dissection should be ruled out as an embolic source.

Controlling air leaks using free pericardial fat pads as surgical sealant in pulmonary resection.

BACKGROUND: This study evaluated the feasibility and efficacy of a new operative method for controlling intraoperative air leaks using free pericardial fat pads as a covering sealant in pulmonary resection. METHODS: To manage air leaks that must be controlled in pulmonary resection at the first water sealing test, collected free pericardial fat was used as a covering sealant and sewn on by the suture closing the lesion. In cases of uncontrolled air leaks at the second sealing test, fibrin glue was used to fill the residual lesion between the fat and visceral pleura. Fifty-one eligible patients were enrolled in this study to evaluate the duration of postoperative air leaks and the condition of the implanted fat on chest computed tomography (CT) 6 months later. RESULTS: The mean duration of postoperative air leaks was 1.05 ± 1.84 days in the 39 cases that received the pericardial fat covering technique only and 2.66 ± 3.42 days in the 12 cases that received the pericardial fat covering technique combined with fibrin glue. Prolonged alveolar air leaks occurred in 1 case and 2 cases, respectively. No cases required conversion to conventional methods, and there were no further adverse events. On follow-up chest CT approximately 62.7% of obvious engrafted fat survived. CONCLUSIONS: Using free pericardial fat pads as a sealant to control air leaks in pulmonary resection is safe and has good feasibility and potent efficacy. This new method can be an innovative technique for preventing prolonged air leaks.

Renal redox dysregulation in AKI: application for oxidative stress marker of AKI.

Oxidative stress is a major determinant of acute kidney injury (AKI); however, the effects of an AKI on renal redox system are unclear, and few existing AKI markers are suitable for evaluating oxidative stress. We measured urinary levels of the redox-regulatory protein thioredoxin 1 (TRX1) in patients with various kinds of kidney disease and in mice with renal ischemia-reperfusion injury. Urinary TRX1 levels were markedly higher in patients with AKI than in those with chronic kidney disease or in healthy subjects. In a receiver operating characteristic curve analysis to differentiate between AKI and other renal diseases, the area under the curve for urinary TRX1 was 0.94 (95% confidence interval, 0.90-0.98), and the sensitivity and specificity were 0.88 and 0.88, respectively, at the optimal cutoff value of 43.0 µg/g creatinine. Immunostaining revealed TRX1 to be diffusely distributed in the tubules of normal kidneys, but to be shifted to the brush borders or urinary lumen in injured tubules in both mice and humans with AKI. Urinary TRX1 in AKI was predominantly in the oxidized form. In cultured human proximal tubular epithelial cells, hydrogen peroxide specifically and dose dependently increased TRX1 levels in the culture supernatant, while reducing intracellular levels. These findings suggest that urinary TRX1 is an oxidative stress-specific biomarker useful for distinguishing AKI from chronic kidney disease and healthy kidneys.

Improve morbidity and mortality in coronary artery bypass graft surgery for severe atherosclerosis.

OBJECTIVES: Atherosclerosis has been identified as a risk factor for both morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). To investigate outcomes following CABG for severe atherosclerosis, and to determine whether different surgical techniques can reduce the risk of neurologic events in these patients. METHODS: We studied 225 consecutive patients who underwent elective isolated CABG. Routine preoperative and intraoperative examinations identified patients with severe atherosclerosis. We compared the outcomes between patients with (group A; 42 ceses) and those without (group N; 183 cases) severe atherosclerosis. RESULTS: 36 patients (85.7%) in group A and 176 (96.2%) in group N underwent off-pump coronary artery bypass (OPCAB); 6 (14.3%) in group A and 7 (3.8%) in group N underwent on-pump beating CABG. Three patients in group A suffered deep sternal infection (7.1%), and one suffered stroke (2.4%) compared with none in group N. No cerebral infarction or neurologic events occurred in patients who underwent OPCAB (n = 212, 94.2%). CONCLUSIONS: Prevalence of complications was significantly greater among patients with severe atherosclerotic disease who underwent OPCAB than in those without atherosclerotic disease. Careful selection of surgical strategies can prevent perioperative stroke and reduce mortality.

Aortic valve destruction and pseudoaneurysm of the sinus of Valsalva associated with infective endocarditis.

We report the successful surgical treatment of a case of aortic valve destruction and pseudoaneurysm of the sinus of Valsalva associated with infective endocarditis (IE) in an 80-year-old woman. Multidetector-row computed tomography revealed an abnormal cavity in the left posterior aortic root. We had made the diagnosis of the aortic valve destruction and saccular pseudoaneurysm of the sinus of Valsalva associated with IE. Aortic valve replacement and patch plasty of the left sinus of Valsalva was performed successfully. A histopathologic examination of the resected aortic valve leaflet revealed inflammatory changes consistent with IE. We describe the surgical technique used in this rare case of pseudoaneurysm of the sinus of Valsalva resulting from IE.

A ball-shaped thrombus of the tricuspid valve after VSD closure.

We report successful surgical management of a 26-year-old man with a ball-shaped thrombus of the tricuspid valve. He had been treated with prednisolone for IgA nephropathy and undergone surgical closure of an isolated ventricular septal defect (VSD). No symptoms, coagulative disorders, or pulmonary embolisms were found. Preoperative echocardiography showed a ball-shaped mass that had originated from the anterior leaflet of the tricuspid valve; it also revealed a small residual VSD. A histological examination revealed the mass to be an organized thrombus with no tumor components. This was a rare case of excision of an organized thrombus of the tricuspid valve. The findings suggest that the thrombus formation may have been associated with the small shunt and/or prednisolone.

Platelet-derived endothelial cell growth factor gene therapy for limb ischemia.

OBJECTIVES: Platelet-derived endothelial cell growth factor (PD-ECGF) is identical to thymidine phosphorylase (TP), and it can induce angiogenesis, including arteriogenesis, in chronically ischemic canine myocardium. Because its effect on peripheral arterial disease has not been elucidated, we investigated whether overexpression of PD-ECGF/TP could ameliorate chronic limb ischemia in rabbits. METHODS: Left femoral arteries were resected from 24 male rabbits. After 10 days, a plasmid vector containing human PD-ECGF/TP complimentary DNA was injected into 10 sites in the adductor muscles. Control groups received either the LacZ plasmid vector or saline vehicle only (n = 8 per group). Blood pressure was measured in the calf before surgery, at the onset of ischemia, 10 days later, and 20 and 30 days after gene transfer. Collateral vessel development and limb perfusion were assessed by angiography, and resected tissues underwent molecular and histologic examination. RESULTS: In the PD-ECGF/TP group, human PD-ECGF/TP messenger RNA and protein were still detected at 30 days after treatment. Calf blood pressure decreased significantly after femoral artery resection in all three groups. It subsequently showed a greater increase in the PD-ECGF/TP group than in either control group, and the difference was significant at 20 days after treatment (PD-ECGF/TP, 97.4 +/- 7.4; LacZ, 58.6 +/- 6.9; saline, 41.3 +/- 3.6). Immunohistochemical staining demonstrated an increased ratio of capillaries and arterioles to muscle fibers in the PD-ECGF/TP group (2.14 +/- 0.13 and 1.51 +/- 0.06), but not in the LacZ group (1.39 +/- 0.04 and 0.71 +/- 0.05) or the saline group (1.34 +/- 0.05 and 0.71 +/- 0.04, P < .01). The angiographic score was higher in the PD-ECGF/TP group (0.96 +/- 0.08) than in the LacZ group (0.50 +/- 0.02) or saline group (0.51 +/- 0.03) at 30 days after gene transfer (P < .01). CONCLUSIONS: This study demonstrated that PD-ECGF/TP gene transfer induced angiogenesis and decreased ischemia in a rabbit hindlimb model by promoting arteriogenesis, suggesting that targeting this gene may be a promising therapeutic strategy for peripheral vascular disease.

Adventitial inversion technique without the aid of biologic glue or Teflon buttress for acute type A aortic dissection.

OBJECTIVE: This study was performed to evaluate the clinical usefulness of the adventitial inversion technique in acute type A aortic dissection, with special attention to the impact of this procedure on the postoperative status of false lumen evaluated by computed tomographic scan. METHODS: From March 2001 to November 2004, 18 consecutive patients underwent emergent surgery for acute type A aortic dissection. Supracoronary graft replacement was performed in all the patients (ascending aorta/hemiarch replacement: 13/18=72%, total arch replacement: 5/18=28%). The adventitial inversion technique was used for both the proximal and the distal stump constructions of the dissected aortic wall without the aid of Teflon felt or biologic glue. Aortic regurgitation was treated with resuspension of the aortic commissures. RESULTS: There were two hospital deaths and the overall hospital mortality rate was 11.1%. The mean postoperative blood loss was 635+/-214 ml and no reexploration was required in any of the patients. Postoperative computed tomography showed closure of the false lumen in aortic root, aortic arch, and proximal descending thoracic aorta in all of the surviving patients. Postoperative echocardiography demonstrated no aortic regurgitation in any of the patients. Two patients died late postoperatively from unrelated causes to aortic dissection. The remaining 14 patients are doing well without a second-stage operation for aortic root or distal aortic lesions during the follow-up period of 7-51 months (mean: 28+/-14 months). CONCLUSIONS: The adventitial inversion technique provides an excellent immediate hemostasis and facilitates thrombotic closure of the proximal and the distal false lumen in the treatment for acute type A aortic dissection.

Thymidine phosphorylase gene transfer inhibits vascular smooth muscle cell proliferation by upregulating heme oxygenase-1 and p27KIP1.

OBJECTIVE: Thymidine phosphorylase (TP) reportedly promotes endothelial cell migration and induces heme oxygenase (HO)-1 expression. However, its effect on vascular smooth muscle cells (VSMCs) is poorly understood. In this study, we examined the effect of TP on VSMCs in vitro and in vivo. METHODS AND RESULTS: Phagemid vector encoding human TP gene was transfected into rat VSMCs, and a clone overexpressing TP was selected (C2). C2 showed a slower migration and proliferation than VSMCs cloned with empty vector (pC) under basal, serum-stimulated, and hypoxic conditions. This decrease in proliferation correlated with TP-induced HO-1 expression and was reversed by inhibitors of either TP or HO activity. Furthermore, in C2, the cyclin-dependent kinase inhibitor (p27KIP1) was much more abundant than in pC, and the cell cycle was arrested at the G1 phase. TP or HO activity inhibitors decreased p27(KIP1) expression in C2 to the level seen in pC. Adventitial TP gene delivery significantly reduced neointimal VSMC migration and neointima formation in balloon-injured rat carotid arteries. CONCLUSIONS: TP overexpression upregulated HO-1 expression and consequently increased p27(KIP1) in cultured VSMCs, and inhibited VSMC migration and proliferation in vitro and in vivo. TP represents a promising target for treating vascular obstructive disease.

[A case of advanced gastric cancer with peritonitis carcinomatosa resected with intraperitoneal chemotherapy based on chemosensitivity test with ascites].

The patient was a 57-year-old man who developed obstructive jaundice and pancreatitis. He was diagnosed with peritonitis carcinomatosa from gastric cancer, and the cancers were unresectable at first laparotomy. We gathered the accumulated ascites and examined the fluid by chemosensitivity test. Some anti-cancer drugs were selected based on the test results of test, and four cycles of modified PMUE therapy (CDDP ip, MMC iv, ETP po, UFT-E po) were performed. This chemotherapy proved very effective, and the cytodiagnostic malignancy with ascites changed from class V to II before and after chemotherapy. Following chemotherapy, a re-laparotomy was performed and a curability B operation could be undertaken. He survived for 17 months after the first laparotomy, but died of extra-peritoneal recurrence in the pelvic cavity. Treatment of advanced gastric cancers with peritonitis carcinomatosa is very difficult, because none of the various therapies (operation, chemotherapy, hyperthermia etc.) can completely control dissemination. It is very effective when the chemosensitivity of individual cancers is clear before chemotherapy. The current chemosensitivity test with ascites is still technically incomplete, but it may contribute to improved treatment of cancers with peritonitis carcinomatosa in the future.

Giant mediastinal bronchial artery aneurysm mimicking benign esophageal tumor: a case report and review of 26 cases from literature.

Mediastinal bronchial artery aneurysm is rare but potentially life-threatening, and requires prompt treatment to avert rupture with catastrophic results. A 78-year-old man was referred to our hospital with a benign esophageal tumor, which appeared as an extrinsic, extramucosal filling defect on an esophagogram. Chest computed tomography and selective bronchial arteriography led to a definitive diagnosis of mediastinal bronchial artery aneurysm. Aneurysmectomy and closure of the ostia of both the afferent and efferent bronchial arteries was performed via standard posterolateral thoracotomy. Postoperative course was uneventful, and the patient was discharged on the seventh postoperative day.