Effects of voltage strength during electroporation on the development and quality of in vitro-produced porcine embryos.

This study was conducted to determine suitable conditions for an experimental method in which the CRISPR/Cas9 system is introduced into in vitro-produced porcine zygotes by electroporation. In the first experiment, when putative zygotes derived from in vitro fertilization (IVF) were electroporated by either unipolar or bipolar pulses, keeping the voltage, pulse duration and pulse number fixed at 30 V/mm, 1 msec and five repeats, respectively, the rate of blastocyst formation from zygotes electroporated by bipolar pulses decreased compared to zygotes electroporated by unipolar pulses. In the second experiment, the putative zygotes were electroporated by electroporation voltages ranging from 20 V/mm-40 V/mm with five 1-msec unipolar pulses. The rate of cleavage and blastocyst formation of zygotes electroporated at 40 V/mm was significantly lower (p < .05) than that of zygotes electroporated at less than 30 V/mm. Moreover, the apoptotic nuclei indices of blastocysts derived from zygotes electroporated by voltages greater than 30 V/mm significantly increased compared with those from zygotes electroporated by voltages less than 25 V/mm (p < .05). When zygotes were electroporated with Cas9 mRNA and single-guide RNA (sgRNA) targeting site in the FGF10 exon 3, the proportions of blastocysts with targeted genomic sequences were 7.7% (2/26) and 3.6% (1/28) in the embryos derived from zygotes electroporated at 25 V/mm and 30 V/mm, respectively. Our results indicate that electroporation at 25 V/mm may be an acceptable condition for introducing Cas9 mRNA and sgRNA into pig IVF zygotes under which the viability of the embryos is not significantly affected.

[Effect of sivelestat sodium on acute lung injury after acute aortic dissection].

Acute lung injury is a frequent and serious complication in patients with acute aortic dissection (AAD). Elevated neutrophil elastase has been reported to be one of the major determinants occurring in AAD. On admission, we administered sivelestat sodium hydrate, a neutrophil elastase inhibitor, to 11 patients with AAD who were medically treated to prevent lung injury. We compared their clinical course with that of 12 patients of control group in which sivelestat was not used prophylacticaly. Although there were 5 patients (42%) who suffered from respiratory failure and needed mechanical ventilation in the control group, no one needed intubation in the sivelestat group. Our study suggested that sivelestat sodium hydrate could be effective in preventing intubation due to respiratory failure. Further prospective study is necessary to evaluate prophylactic administration of sivelestat sodium hydrate in AAD.

[Reconstruction of neck vessels in endovascular repair of aortic arch aneurysms].

We report 6 cases of aortic arch aneurysms necessitating reconstruction of the neck vessel during stent-graft (SG) placement. All patients were male and their average age was 75 years. The proximal landing zone was zone 0 in 2, zone 1 in 2, and zone 2 in 2 patients. The left subclavian artery (LSCA) was revascularized in every case; using left common carotid artery (LCCA)-LSCA bypass in 3, axillo-axillary artery bypass in 2, and LSCA transposition in 1. Prophylactic LCCA revascularization was done in 2 in which obstruction of LCCA by SG was anticipated. The proximal portion of LSCA from the origin of the vertebral artery was ligated in 3, and divided in 1. Two types of SG were used; Z stent in 1 and Matsui-Kitamura stent in 5. There was no hospital death or perioperative stroke. In the patient with Z stent, SG could not be deployed because of kinking of the delivery system. This patient subsequently underwent surgical SG placement under hypothermic circulatory arrest. In the other 5, SG was deployed without any type of endoleak. Postoperative complication included incomplete phrenic nerve palsy in 1. Prophylactic bypass for LCCA was divided because SG did not obstruct the antegrade flow of LCCA. Revascularization of neck vessels can be performed with low morbidity in endovascular repair of aortic arch aneurysms.

[Hemiarch replacement and concomitant valve repair for proximal aortic aneurysm accompanying bicuspid aortic valve with mild regurgitation].

A 64-year-old man who had proximal aortic aneurysm and bicuspid aortic valve with mild regurgitation underwent hemiarch replacement and concomitant valve repair under selective cerebral perfusion and deep hypothermic circulatory arrest. Valve repair technique consisted of leaflet plication according to Schaefers and subcommissural annular plication. No homologous transfusion was required, and the patient was extubated 5.5 hours after surgery. The repaired valve showed trivial regurgitation and no stenosis, and remained stable 22 months after surgery. Schaefers' technique of aortic leaflet plication is simple and reproducible, and is therefore recommendable for such cases.

Importance of early repair of isolated abdominal aortic dissecting aneurysm.

BACKGROUND: Since the available information on isolated abdominal aortic dissecting aneurysm (AADA) is mainly related to case reports or reports of small groups of patients, its natural history remains undetermined and there is no agreement on its optimal management. The purpose of this study is to define the features and pattern of development of this unusual entity as well as to propose criteria for treatment based on our own experience and previously published data. PATIENTS AND METHODS: We retrospectively evaluated the history of 6 patients diagnosed with AADA. The patients were 5 males and 1 female. The mean age was 71 +/- 8 years (range: 61-80 years), and the mean aneurysm diameter was 54 +/- 14 mm (range: 35-70 mm). All of these patients were hypertensive (100%). History of cerebrovascular accident, ischemic heart disease, peripheral arterial disease, or diabetes mellitus was present in 1 patient, respectively. Two patients developed mycotic AADA. RESULTS: Emergency operations had been performed in 3 cases, and scheduled surgical reconstruction in the remaining 3 cases. Operation consisted of aneurysmectomy and graft replacement of the diseased aortic segment in all cases. One patient treated in an emergency setting died subsequently of multisystem organ failure, but the others did well. CONCLUSION: Symptomatic patients or patients at good risk should undergo surgical repair earlier than in the case of abdominal aortic aneurysm without dissection (AAA). Dissection in addition to an AAA will further increase the weakness of the aortic wall and the possibility of aortic rupture will become higher.

[Risk factors for the surgical repair of ventricular septal perforation; an 8-year multiinstitutional analysis].

OBJECTIVE: The purpose of this study was to determine the surgical outcomes and risk factors for surgical repair of the ventricular septal perforation (VSP). METHOD: From 1995 to 2003, 41 patients with VSP underwent surgical repair. There were 18 males and 23 females, with the mean age of 71.7 +/- 9.2. Sixteen patients (39.0%) had the preoperative shock, while 30 patients received intraaortic balloon pumping (IABP) assistance and 1 of those required percutaneous cardiopulmonary support (PCPS). Mean durations from onset of myocardial infarction and VSP to operation were 5.8 +/- 9.4 and 2.4 +/- 8.1 days, respectively. Twenty-six patients underwent infarct exclusion technique, 11 underwent patch closure, and 4 Daggett operation. Mean cardiopulmonary and aortic cross-clamp time were 211 +/- 85 and 105 +/- 43 minutes, respectively. RESULTS: Thirty days mortality was 11 (26.8%). Nine patients (22%) required PCPS after repair, however, 2 weaned off the support and only 1 discharged the hospital. Residual shunt was found in 12 patients (29.3%), and 4 underwent the reclosure of the residual shunt 13 +/- 8.6 days after the initial operation, whereas none of patients with PCPS had residual shunt. Univariate analysis revealed the preoperative shock (p = 0.03), longer cardiopulmonary bypass time (p < 0.01), and the need for PCPS after repair (p < 0.01) were the risk factors for the early mortality. Multivariate analysis indicated the cardiopulmonary time over 210 minutes and the need for PCPS to be the significant risk factors. CONCLUSION: The long cardiopulmonary bypass support after repair and the subsequent need for PCPS imply the poor left ventricular function. Since the residual shunt was not the cause of PCPS, the surgical outcome for VSP may be limited in patients with poor left ventricular function. In these patients, other therapeutic strategies may be required, such as ventricular assisting devices, transplantation, or regenerative therapy.

The less incisional retroperitoneal approach for abdominal aortic aneurysm repair to prevent postoperative flank bulge.

One of the postoperative complications of retroperitoneal incision is a flank bulge that is suggested to be caused by 11th intercostal nerve injury leading to denervation of the ipsilateral muscles. To avoid this complication, we have tried to minimize retroperitoneal incision for abdominal aortic aneurysm (AAA) repair. The feasibility of the less incisional retroperitoneal approach for the repair of AAA to prevent postoperative flank bulge was investigated. Twenty-seven patients undergoing elective repair for infrarenal AAA through the left retroperitoneal approach were divided into group-L (less incision: 11.9+/-1.8 cm, n = 7) and group-C (conventional incision: 17.8+/-1.9 cm, n = 20). All operations were performed by a traditional hand-sewn anastomosis without laparoscopic support. Five bifurcated grafts were used in group-L and 15 in group-C. The postoperative course of all patients was uneventful except that one patient in group-C required reoperation for bleeding. Intraoperative parameters of both groups were almost comparable. All patients in group-L were extubated in the operating theater, whereas it was possible only for 11 patients in group-C. Resumption of alimentation was significantly earlier in group-L (P = 0.0117). There was no significant difference in postoperative hospital stay between groups. No late flank bulge was experienced. Significant late atrophy of the left rectus muscle (left/right thickness-ratio = 0.59+/-0.24) was seen in group-C (P = 0.0042 vs preoperative value), which was not observed in group-L (P = 0.0008 between groups). The less incisional retroperitoneal AAA repair seems feasible and safety technique that might prevent postoperative flank bulge and reduce surgical stress.

Off-pump ascending to descending aorta bypass grafting with descending aneurysm exclusion.

We performed an ascending to descending aorta bypass grafting with exclusion of the descending thoracic aortic aneurysm through a median sternotomy incision without cardiopulmonary bypass in a patient with severe chronic obstructive pulmonary disease. The patient was a 75-year-old man who had undergone endovascular stent-graft placement for a descending thoracic aortic aneurysm. The operation became necessary because the aneurysm continued to expand without evidence of endoleak. The postoperative course was uneventful, and without respiratory morbidity.

[Aberrant subclavian artery].

Aberrant subclavian artery (ASA) is the most frequently encountered congenital anomaly of aortic arch. The ASA aneurysms are rare but potentially lethal disease, it has been recognized that the presence of an aneurysm of an ASA itself is an indication for surgery. We experienced 4 cases with ASA during the past 23 years. All cases were male. Their ages ranged from 51 to 73 years old. Three patients had a right-sided aortic arch. Among the 4 patients, only 1 underwent total arch replacement, but the other 3 patients could be followed conservatively for 1, 7 and 23 years, respectively. We reviewed the problem of the diagnosis and treatment of the ASA including surgical indication.

[Strategy for spinal cord protection during thoracoabdominal aortic surgery].

INTRODUCTION: Our basic strategy for spinal cord protection during thoracoabdominal aortic surgery has been established since August 1994 such as: 1) distal aortic perfusion using partial cardiopulmonary bypass (32-34 degrees C), 2) multi-segmental sequential clamping, 3) deep hypothermic circulatory arrest when sequential clamping is impossible, 4) evoked spinal cord potential-guided reconstruction of the critical intercostal arteries (preoperative evaluation using multi-detector row computed tomography), 5) cerebrospinal fluid drainage, and 6) administration of naloxone hydrochloride and methylprednisolone. In this paper, we analyzed clinical outcome of thoracoabdominal aortic surgery according to this strategy. MATERIALS AND METHODS: We have performed thoracoabdominal aortic surgery for 84 patients (52 male, mean 62 +/- 12 years old) during 1991-2003. Their etiology was 34 dissection, 44 non-dissection degenerative disease, 3 pseudo-aneurysm, and 3 infection. Ten operations were performed urgently and 8 emergently. Crawford's classification (type I/II/III/IV/V) was 17/28/17/13/9 for each type. We used partial cardiopulmonary bypass for 67 cases and deep hypothermic circulatory arrest for 14. RESULTS: For overall/elective cases (n = 84/66), we experienced 13.1/12.1% of incidence of spinal cord injury (paraplegia/paraparesis) and 8.3/4.5% of in-hospital mortality. Within 65 cases (55 elective) operated after August 1994, they decreased up to 7.7/5.5% (0% in type II) and 4.6/1.8%, respectively. Paraplegia was experienced in 2 patients before and 2 patients (emergent operations due to infective aneurysm) after August 1994 (4.8%). Thus, we have experienced no paraplegia in elective cases after establishment of our strategy. CONCLUSIONS: Our strategy for spinal cord protection during thoracoabdominal aortic surgery could provide acceptable clinical outcome and seemed justified.

[Individual temperature management during thoracoabdominal aortic aneurysm repair using separate perfusion of upper and lower torso].

We report thoracoabdominal aortic aneurysm repair using separate perfusion of upper and lower torso that can control temperature of each organ individually. This novel modality can maintain mild hypothermic organ perfusion in upper torso and protect the heart under empty beating, while lower torso is further cooled to protect the spinal cord and visceral organs. Therefore this technique may be useful for patients with heart disease who require complex reconstruction of the intercostal arteries or visceral branches. We used this technique successfully in a patient who has a history of surgical repair of the aortic arch and the abdominal aorta. A 70-year-old male who had a history of abdominal aortic aneurysm repair and aortic arch aneurysm repair using stented elephant trunk underwent Crawford's type II thoracoabdominal aortic aneurysm repair. Three pairs of the intercostal arteries and 4 visceral branches were reconstructed using this technique successfully.

Stenosis of the abdominal aorta caused by fibromuscular dysplasia.

Fibromuscular dysplasia of the aorta is an exceedingly rare disease with 26 cases reported to date in Medline. We present a case of stenosis of the infrarenal abdominal aorta in a 49-year-old woman with a history of intermittent claudication. The patient underwent aortic endarterectomy, and subsequent anatomopathologic examination of the specimen revealed fibromuscular dysplasia. The possible causes of aortic stenosis in this case, its angiographic findings, and the alternatives of treatment are discussed.

[Infected false aneurysm due to methicillin-resistant staphylococcus aureus after proximal aortic grafting].

A 70-year-old man developed meticillin-resistant staphylococcus aureus (MRSA) mediastinitis after prosthetic graft replacement of the ascending aorta. The sternal wound was reexplored and a single-stage procedure of irrigation, debridement, and omental transposition was performed. Ten months after the first operation, he suffered recurrence of pyrexia and the presence of false aneurysm originated from the distal suture line was diagnosed by the chest computed tomography (CT) scan. Re-replacement of the ascending aorta and proximal hemiarch with rifampicin soaked Gelseal was successfully performed. Hypothermic perfusion with circulatory arrest through peripheral cannulation and left ventricular venting via a left anterior thoracotomy was useful to obtain safe reentry in the operation of retrosternal false aneurysm.

[Surgical results for aortic involvement in Marfan syndrome].

From 1991 through 2001, 21 Marfan patients underwent aortic operations in our hospital. They received a total of 36 aortic operations, 31 by ourselves including 4 non-elective operations and 2 operations before 1991. Extent of replacement was Bentall + total arch (4), Bentall (8), valve sparing aortic root (reimplantation) (2), re-anastomosis + coronary aortic bypass grafting (CABG) after Bentall (1), ascending + total arch (3), ascending (1), total arch (1), total thoracoabdominal (10), thoracoabdominal (1), descending thoracic (2), distal arch (1), abdominal (2). Multiple operations were required in 11 patients (2 operations in 7, 3 operations in 4). Eight reoperations in 6 patients were for adjacent lesion, 5 reoperations were for remote lesion, and 2 others were for complication of Bentall (initial operation elsewhere). Among the 8 reoperations for adjacent lesion, 3 were scheduled operation (2 with elephant trunk), 4 were for residual dissection, and 1 was for annulo-aortic ectasia (AAE). Total aortic replacement was achieved in 4 and subtotal replacement excluding the root in 2. There was no hospital mortality. Paraparesis occurred in 1 who died 4.7 years after operation. The remaining patients are currently alive. No other aortic event occurred. Aortic reoperation-free survival was 83% at 5 year and 28% at 10 year.

[An evaluation of the potential ischemia of the forearm after harvesting of radial artery by near infrared spectroscopy].

We evaluated the potential ischemia of the forearm after harvesting of radial artery (RA) for coronary artery bypass grafting (CABG) by near infrared spectroscopy (NIRS). The subjects consist of two groups; patients group (group P) including 18 patients who received CABG with RA and control group (group C) including 9 healthy volunteers. Group P was divided into two groups; early post operative group (group E, n = 11) and mid-term post operative group (group M, n = 7). NIRS was used to measure the recovery time (RT) in the muscles of the forearm during occlusion test. There was a significant prolongation of the RT in group P than group C. There was no significant difference of the RT between group E and group M. In conclusion, harvesting of RA may cause ischemia of the forearm and it may continue for a long time.

[Early and long-term results of surgery for aortic arch aneurysms using selective cerebral perfusion].

OBJECTIVE: We report our operative technique for atherosclerotic arch aneurysms and early and long term results of the surgery. METHODS: Between April 1992 and December 2001, 80 consecutive patients underwent operation for atherosclerotic arch aneurysms. Their mean age was 70 +/- 7 years. Sixty-six (82.5%) patients were operated on electively. All operations were performed under median sternotomy using hypothermic circulatory arrest and selective antegrade cerebral perfusion. Total arch replacement was performed in 66 cases, proximal hemiarch replacement in 4 cases, distal arch replacement using stent graft implantation via aortic arch incision in 8 cases, and patch angioplasty in 2 cases. In 9 of these patients in whom mobile arch atheroma was revealed by intraoperative epiaortic ultrasonography, isolation technique was employed to avoid embolic stroke. RESULTS: Overall in-hospital mortality was 10.0% (8 of 80 patients). Postoperative temporary neurologic dysfunction was 7.5%, and stroke rate was 5.0%. The 3-year, and 5-year actuarial survival rate including hospital death was 79.3% and 75.3% respectively. The 3-year, and 5-year cardiovascular event free survival rate was 68.3% and 60.0% respectively. CONCLUSION: The early and long-term results of surgery for atherosclerotic arch aneurysms were acceptable. Selective cerebral perfusion is an effective brain protective adjunct.

Successful endovascular stent-grafting for thoracic aortic aneurysms in systemic lupus erithematosus. Report of 2 cases and review of the literature.

Systemic lupus erythematosus (SLE) is frequently associated with cardiovascular manifestations but rarely complicated with aortic disease, and surgical treatment is often complicated with later anastomotic dehiscence. We report successful endovascular stent-graft placement (EVSGP) as an alternative to conventional treatment of the aortic aneurysm in patients with SLE and review of the literature. Clinical cases included a 58-year-old woman with a saccular aneurysm of the distal aortic arch and a 52-year-old woman who had the aortic dissection in the whole descending thoracic aorta. Both patients underwent placement of the stent-graft in the diseased aorta through the iliac artery and received steroid perioperatively. Mortality was compared between surgical and medical treatment in the reported 39 cases of SLE associated with aortic aneurysm. Both patients were successfully treated by EVSGP and no inflammatory signs were seen after the procedure. There were no recurrence in the short follow-up period (up to 23 and 15 months after the procedure). In review of the literature, operative mortality (13.6%) was superior to that in patients receiving medical treatment only (53.3%), but two of 19 operative survivors died of rupture afterward. EVSGP can be a useful alternative to conventional treatment of the aortic aneurysm in patients with SLE, although it lacks the support of long-term follow-up data currently.

A case of an ascending aortic aneurysm due to mesoaortitis complicated with idiopathic thrombocytopenic purpura.

An 80-year-old man was referred to our hospital for the surgical treatment of an ascending aortic aneurysm. The diagnosis of idiopathic thombocytonenic purpura was also made by hematological studies which included the examination of the aspirated bone marrow. Preoperative chest computed tomography showed an ascending aortic aneurysm with a maximum diameter of 80 mm. Echocardiography demonstrated mild aortic regurgitation. The platelet count increased by intravenous administration of immunoglobulin. A prosthetic graft replacement of the ascending aorta and aortic valve repair were carried out with the aid of cardiopulmonary bypass, selective cerebral perfusion and hypothermic circulatory arrest. No difficulty was encountered in hemostasis and the postoperative course was uneventful. Histological examination of the aneurysmal wall showed chronic mesoaortitis with patchy destruction of musculo-elastic medial tissue and adventitial focal lymphocytic infiltrates that were similar to syphilitic mesoaortitis, although serological treponemal tests were all negative. Perioperative administration of gamma-globulin is useful to minimize the hemorrhagic complication in a patient undergoing cardiovascular surgery with idiopathic thrombocytopenic purpura.