Autocrine Regulation of Interleukin-6 via the Activation of STAT3 and Akt in Cardiac Myxoma Cells.

Plasma concentrations of a pleiotropic cytokine, interleukin (IL)-6, are increased in patients with cardiac myxoma. We investigated the regulation of IL-6 in cardiac myxoma. Immunohistochemical staining and reverse transcription-polymerase chain reaction (RT-PCR) revealed that IL-6 and its receptors, IL-6 receptor (IL-6R) and gp130, co-existed in the myxoma cells. Myxoma cells were cultured, and an antibody array assay showed that a conditioned medium derived from the cultured myxoma cells contained increased amounts of IL-6. Signal transducer and activator of transcription (STAT) 3 and Akt were constitutively phosphorylated in the myxoma cells. An enzyme-linked immunosorbent assay (ELISA) showed that the myxoma cells spontaneously secreted IL-6 into the culture medium. Real-time PCR revealed that stimulation with IL-6 + soluble IL-6R (sIL6R) significantly increased IL-6 mRNA in the myxoma cells. Pharmacological inhibitors of STAT3 and Akt inhibited the IL-6 + sIL-6R-induced gene expression of IL-6 and the spontaneous secretion of IL-6. In addition, IL-6 + sIL-6R-induced translocation of phosphorylated STAT3 to the nucleus was also blocked by STAT3 inhibitors. This study has demonstrated that IL-6 increases its own production via STAT3 and Akt pathways in cardiac myxoma cells. Autocrine regulation of IL-6 may play an important role in the pathophysiology of patients with cardiac myxoma.

Successful sutureless repair of multiple left ventricular free wall ruptures due to Takotsubo cardiomyopathy: a case report.

BACKGROUND: Takotsubo cardiomyopathy (TCM) is a temporary and reversible systolic abnormality of the left ventricular apical area resembling a myocardial infarction. Cardiac rupture due to TCM is a rare but fatal complication. Without cardiac surgery, 94% of patients with left ventricular free wall rupture (LVFWR) due to TCM die. Furthermore, successful surgical cases are rare. We report herein the successful treatment of multiple LVFWRs due to TCM using a sutureless repair. CASE PRESENTATION: An 80-year-old man quarreled with his daughter and had a sudden onset of chest pain. He was transferred to our hospital in shock. Electrocardiography showed ST elevation and contrast-enhanced computed tomography revealed a bloody pericardial effusion. Emergent coronary angiography showed no significant stenosis. Cardiac arrest ensued because of cardiac tamponade. Emergent surgery was undertaken and three oozing lacerations on the lateral and inferior walls were noted. A sutureless repair was performed using TachoSil® patches. We also applied Surgicel Nu-Knit® absorbable hemostat with Hydrofit® where TachoSil® failed to completely adhere because of hematoma formation and achieved complete hemostasis. We diagnosed the ruptures due to TCM according to the Mayo criteria. The patient was discharged on postoperative day 71. CONCLUSIONS: A sutureless repair using TachoSil® patches and Surgicel® with Hydrofit® is a minimally invasive and effective method for the treatment of multiple LVFWRs due to TCM.

[Experience with a New Negative Pressure Incisional Wound Management System in Cardiac Surgery].

We report on the efficacy of the Prevena incisional wound management system, a negative pressure wound care system, in patients at a high risk of wound infection following cardiac surgery. METHODS: Ten patients with a mean Fowler risk score of 4.6( 1.6~9.9) were included. The Prevena system was applied immediately after surgery and used for 5 days while negative pressure of -125 mmHg was continuously applied, and the condition of the wound and surrounding skin was evaluated immediately after removal of the Prevena system. RESULT: Ten patients had completely healed wounds, and no skin damage around the wound due to negative pressure after removal of the Prevena system was observed. No skin damage was observed around the wound after removal of the Prevena system, and no wound complications occurred until discharge. CONCLUSIONS: The Prevena system is safe, easy to use, and useful for wound healing in patients at a high risk for wound complications after cardiac surgery.

[Transprosthetic Cuff Leakage of the MITRIS RESILIA Mitral Valve During Mitral Valve Replacement:Report of a Case].

An 82-year-old woman was referred to our hospital because of severe mitral valve regurgitation( MR)with symptoms of heart failure. Preoperative transesophageal echocardiography( TEE) showed P2 prolapse due to chordal rupture, severe calcification of P2, and mild tricuspid valve regurgitation. The patient underwent mitral valve replacement using the MITRIS RESILIA mitral valve and tricuspid annuloplasty. Intraoperative TEE showed a mild regurgitation from the cuff on the A1P1 side at the mitral valve position. After the second aortic declamping, 4-0 prolene felted mattress suture was placed on the needle hole in the cuff. In repeat TEE, regurgitation improved to trace. Postoperative echocardiography confirmed disappearance of transprosthetic cuff leakage at the mitral valve, and the patient was discharged on postoperative day 36. We experienced a transprothetic cuff leakage, which is the first case on the MITRIS RESILIA mitral valve.

Prosthetic vascular graft rupture caused by claw-type rib fixation strut: a case report.

A 66-year-old-man who had undergone partial aortic arch and descending aortic graft replacement for a dissecting aortic aneurysm presented to our hospital with pain and beating swelling of his left back shoulder. Enhanced computed tomography and aortic angiography revealed graft rupture caused by one of the claws of a rib fixation strut. Furthermore, another claw had invaded a lung. We performed emergency thoracic endovascular aortic repair, and removed all of the struts 3 weeks later. Claw-type rib fixation struts have the potential to injure other organs, including prosthetic grafts. Careful follow-up is mandatory after implantation of this type of strut.

Pancreaticoduodenectomy after transcatheter aortic valve implantation in an elderly patient with severe aortic stenosis and pancreas cancer: A case report.

INTRODUCTION AND IMPORTANCE: Not only pancreatic cancer but also aortic stenosis (AS) is increasing with the aging population. There is no optimal strategy for elderly patients with both pancreatic cancer and AS. We report a case of pancreatic head cancer with severe AS undergoing pancreaticoduodenectomy (PD) after transcatheter aortic valve implantation (TAVI). CASE PRESENTATION: An 88-year-old woman was referred to our hospital because of severe AS with symptoms of heart failure. Preoperative examination revealed resectable pancreatic head cancer, so TAVI was performed before PD to reduce the perioperative risk. The patient underwent PD 34 days after TAVI, with no significant postoperative complications, and was transferred to the other hospital for rehabilitation on postoperative day 45. No recurrence was observed at more than 7 months without adjuvant therapy. CLINICAL DISCUSSION: Aortic valve replacement (AVR) is recommended before non-cardiac surgery in patients with symptomatic severe AS. Surgical aortic valve replacement (SAVR) is the standard treatment. However, owing to the highly invasive procedure and increased perioperative risk, SAVR is usually avoided in elderly patients with malignancy and severe AS. We demonstrated that TAVI followed by PD could be safely performed in high-risk elderly patients presenting with both severe AS and pancreatic head cancer. To our knowledge, this is the first case report of PD after TAVI in a patient with severe AS. CONCLUSION: We demonstrated that TAVI followed by PD could be safely performed in high-risk elderly patients presenting with severe AS and co-existing malignancy.

Simultaneous Surgery for Inferior Vena Cava Leiomyosarcoma with Multiple Hepatic Metastases: A Justified Challenge.

BACKGROUND Leiomyosarcoma of inferior vena cava (IVC), a rarely encountered malignancy originating from the smooth muscle cells of media of the IVC, frequently metastasize to the liver. The suggested treatment of choice of IVC leiomyosarcoma is radical en-bloc excision aimed to obtain a negative resection margin. There are a few reported cases of surgical management in patients with liver metastasis from IVC leiomyosarcoma. CASE REPORT This report describes a simultaneous surgical approach for a case of IVC leiomyosarcoma with multiple liver metastases followed by chemotherapy. CONCLUSIONS Tumor volume reduction surgery of metastatic lesions combined with radical resection of the primary tumor may provide better survival benefit in patients with advanced IVC leiomyosarcoma.

[Reconstruction of Anterior Mitral Leaflet Using Fresh Autologous Pericardial Patch for Active Infective Endocarditis;Report of a Case].

Several reports have described that the prognosis of patients with mitral valve regurgitation due to active infective endocarditis (IE) is better after mitral valve plasty (MVP) than replacement (MVR). However, extensive destruction of valve tissue might cause difficulties with MVP. We repaired a widely-affected anterior mitral leaflet (AML) using an autologous pericardial patch. A 44-year-old woman with mitral regurgitation presented with prolonged fever and backache. We made a diagnosis of active IE accompanied by mitral valve regurgitation. We performed MVP, widely resected the infected areas of the AML, and reconstructed the defective area using the pericardial patch. She was discharged after four weeks of antibiotic therapy, when she was free of recurrence. The pericardial patch facilitated MVP and was effective for treating mitral valve regurgitation due to active IE.

[Direct ethanol injection by median sternotomy for a bronchogenic cyst compressing the pulmonary artery and the left atrium].

Bronchogenic cyst is a rare developmental lesion. It can cause symptoms only when infected or pressing on neighboring structures. A 56-year-old woman presenting with orthopnea and chest pain was found to have a bronchogenic cyst compressing the right pulmonary artery and the left atrial roof. The mass adhered to surrounding structures and complete resection of the mass seemed to be technically impossible. Accordingly, a direct ethanol injection therapy with median sternotomy approach was accomplished. After the procedure the patient's symptoms disappeared and the follow-up computed tomography 21 months later revealed no relapse. Though the complete resection of bronchogenic cysts is recommended to confirm the diagnosis, to prevent development of complications, and to avoid recurrences, ethanol injection therapy is still a valid option in some cases.

Effects of recombinant human soluble thrombomodulin treatment for disseminated intravascular coagulation at a single institution--an analysis of 62 cases caused by infectious diseases and 30 cases caused by hematological diseases.

OBJECTIVE: Disseminated intravascular coagulation (DIC) is a clinical condition with high mortality that is characterized by the systemic activation of coagulation pathways resulting in multiple organ failure. Although no standard treatment for DIC has been established, recent reports have indicated that recombinant human soluble thrombomodulin (rTM) is effective against DIC. METHODS: To elucidate the clinical characteristics and outcomes of DIC, we retrospectively analyzed 92 DIC patients who were treated with rTM at Miyazaki Prefectural Hospital over a 4-year period (62 patients had infectious diseases and 30 patients had hematological diseases). A diagnosis of DIC was made based on the diagnostic criteria of the Japanese Association for Acute Medicine (JAAM) and Japanese Ministry of Health and Welfare (JMHW) for infectious diseases and hematological diseases, respectively. In addition to treating the underlying disease, rTM was administered for six consecutive days. RESULTS: In this study, 49 of the 92 DIC patients (53.3%) experienced resolution of DIC seven days after administration (46.8% patients with infectious disease and 66.7% with hematological disease). A higher survival rate was observed after a 28-day observation period in 69 of the 92 patients (75.0%) (72.6% of the patients with infectious disease and 80.0% of the patients with hematological disease). A lower DIC score at the initiation of rTM treatment was closely related to a higher rate of resolution of DIC. CONCLUSION: Our findings indicate that rTM therapy is an effective, safe and feasible treatment for DIC patients. Furthermore, making an accurate and early diagnosis of DIC and providing subsequent immediate treatment with rTM may improve the resolution of DIC.

Effects of ultrasonic skeletonization on internal thoracic and gastroepiploic arteries for coronary artery bypass grafting.

OBJECTIVE: There are few data available on the effect of ultrasonic skeletonization with the harmonic scalpel on internal thoracic artery (ITA) and gastroepiploic artery (GEA) vessel function. METHODS: Rings of segments of the skeletonized ITA, pedicled ITA, skeletonized GEA, and pedicled GEA were studied. Arterial segments were treated with high KCl and norepinephrine (NE) to obtain smooth muscle contractions. Endothelium-dependent and independent vasorelaxant potencies in 10(-6)mol/l NE-pre-constricted arteries were assessed by acetylcholine (ACh), and isosorbide dinitrate (ISDN) and diltiazem, respectively. RESULTS: There were no differences in contractile potencies induced by high KCl and NE between the rings cut from skeletonized and pedicled grafts. The rings from skeletonized and pedicled vessels also showed equal sensitivity to ISDN and diltiazem. However, the rings from pedicled grafts showed greater relaxation responses to ACh than rings from skeletonized grafts. CONCLUSION: Ultrasonic complete skeletonization with the harmonic scalpel may retain smooth muscle function of skeletonized grafts, whereas endothelial function of ultrasonic skeletonized grafts may be significantly compromised.

Posterior mitral annuloplasty through the aortic root.

A case of mitral regurgitation associated with aortic root aneurysm treated with posterior mitral annuloplasty is presented. The annuloplasty was performed through the aortic annulus using valve-preserving aortic root reconstruction. Postoperatively, mitral regurgitation resolved, and the degree of aortic regurgitation decreased from severe to mild. Thus, we conclude that the transaortic approach is useful for simple mitral valve repair with concomitant aortic root surgery.

Late development of mitral regurgitation after left ventricular reconstruction surgery.

PURPOSE: Late presence of mitral regurgitation (MR) after the Dor procedure (left ventricular (LV) reconstruction associated with coronary artery bypass grafting) for postinfarction patients carries a poor prognosis. The aim of this study was to review our experience with the Dor procedure and to analyze the correlation of surgical results with late MR. METHODS: The study group comprised 19 patients with previous anterior transmural myocardial infarction (MI). Ten patients were classified as New York Heart Association (NYHA) functional class III or IV at surgery. MR was moderate in 2 patients and mild in 15 patients. RESULTS: Myocardial revascularization was performed in all patients, with a mean of 3.7+/-1.2 grafts. Mitral valve was repaired in 6 patients. Four patients with mild MR underwent posterior annuloplasty, and 2 with moderate MR underwent rigid annular remodeling. Early postoperative NYHA functional class improved from 2.7+/-0.9 to 1.3+/-0.5; however, MR deteriorated to moderate in 5 patients with worsening NYHA functional class 3 months after surgery. Although the valve was not repaired during surgery in 4 patients with preoperative mild MR, 1 patient with moderate MR underwent annuloplasty with a rigid ring. All patients with late MR underwent more than 30-mL/m2 reduction of end-diastolic volume index at surgery. Cumulative 4-year survival including hospital deaths was 89.5%. CONCLUSION: To prevent the risk of late MR, a more than 30-mL/m2 reduction of end-diastolic volume index should be avoided and mitral valve repair should be performed even if preoperative functional MR is only mild.

Off-pump coronary artery bypass grafting in a patient with congenital factor V deficiency: report of a case.

Congenital factor V deficiency is an uncommon bleeding disorder that necessitates hemostatic correction before surgery. We herein describe a patient with severe factor V deficiency who underwent successful off-pump coronary artery bypass grafting with a transfusion of fresh-frozen plasma.

Off-pump coronary artery bypass grafting in a patient with Behçet's disease.

We report the case of a 58-year-old man with Behçet's disease who developed chest pain. Coronary angiography showed severe triple-vessel disease, and the patient was transferred to our department for urgent coronary artery bypass grafting. Because of the risk of anastomotic leakage or pseudoaneurysm formation, we performed off-pump coronary artery bypass grafting with the aortic no-touch technique. Postoperative coronary angiography showed that all the grafts were patent and no anastomotic pseudoaneurysms were observed. Pathological examination of the right internal thoracic artery specimen revealed mild intimal thickening and disruption of elastic fibers in the medial layer, both of which are characteristics of Behçet's disease. These findings indicated that the patient must be monitored carefully for postoperative pseudoaneurysm formation.

[Iatrogenic myocardial infarction].

In this paper, iatrogenic myocardial infarction resulting from percutaneous catheter intervention (PCI) and cardiac surgery is described. Among the patients who had experienced iatrogenic myocardial infarction in the past 4 years, 6 had undergone emergent coronary artery bypass grafting (CABG). An emergent operation for myocardial infarction was performed on 3 patients, for problems associated with PCI, and 1 patient had died due to cardiac failure. In the latter case, although the emergent CABG was performed after the failure of percutaneous coronary intervention in another hospital, no improvement in cardiac function was observed. The reason for this was that the myocardial damage became almost irreversible due to the delay in transferring the patient to our hospital. An additional CABG was performed in 2 cases, because they experienced a cardiogenic shock after cessation of the cardio-pulmonary bypass system. In these cases, cardiac function had improved immediately after an additional CABG. Some ST elevation in the electrocardiograms was observed in 8 cases in the intensive care unit after isolated CABG. One patient experienced a cardiogenic shock, and was transferred to the operating room immediately. The radial artery graft connected in sequence to circumflex coronary arteries was spastic, and an additional bypass was performed to the same coronary arteries using a saphenous vein graft. Although conservative medical therapy was administered in the remaining 7 cases, 1 case presented an occlusion of the left descending coronary artery, and an emergent CABG should have been performed. ST elevations in 2 cases were caused by coronary spasm, while in the remaining 4 cases, they were caused by pericardiotomy. Although a postoperative change in the electrocardiogram was considered important, the diagnosis was complicated. In myocardial infarction, cardiogenic shock develops easily, and an emergent CABG is needed in many cases. It is important to decide on an emergent operation promptly after an accurate diagnosis.

Infected aneurysm of the ascending aorta in childhood: report of a case.

Infected aneurysms of the thoracic aorta are rare in children, and many are not diagnosed until autopsy. We report the case of a 3-year-old girl in whom an infected aneurysm of the ascending aorta was successfully repaired by Dacron patch angioplasty under cardiopulmonary bypass.

Congenital quadricuspid aortic valve: report of nine surgical cases.

We report the clinicopathologic characteristics of the congenital quadricuspid aortic valve necessitating surgery. Among 616 patients for whom we performed an aortic valve operation over the past 20 years, nine patients (1.46%) (five men and four women, mean age 60 years) with quadricuspid aortic valve were encountered. All had aortic regurgitation (AR) except one with aortic stenosis and mild regurgitation (ASr). All were free of cardiac anomaly including that of the coronary arterial system. Macroscopically, severe calcification of the valve was seen in the one case of ASr. Fenestration of the cusp was seen in five cases of AR. Infective endocarditis was not seen. Histological study disclosed fibrous thickening and myxoid degeneration in the AR cases. In accordance with the Hurwitz and Roberts classification, four valves were type b (three equal-sized cusps and one smaller cusp), two valves were type a (four equal-sized cusps), two valves were type d (one large, two intermediate, and one small cusp), and one valve was type g (four unequal-sized cusps). Valve repair failed in one patient and was converted to valve replacement during the operation. All patients underwent successful aortic valve replacement (AVR).

Aortic valve replacement in a patient with erythropoietic protoporphyria.

Erythropoietic protoporphyria (EPP) is a disorder of heme synthesis that causes excessive accumulation of protoporphyrin. The predominant clinical feature is photosensitivity triggered by light at wavelengths near 400 nm. We describe a 52-year-old man with EPP who underwent aortic valve replacement due to severe regurgitation. To prevent burn injuries, astral lamps in the operating room were covered with yellow film filters. Preoperative autologous blood donation was not undertaken. Blood priming of the extracorporeal circuit was performed to maintain adequate hemoglobin concentrations, which resulted in reduction of heme synthesis. The patient was discharged in good health without any signs or symptoms of EPP.