Endoscopic-assisted Surgical Removal of Infected Interosseous Wires 40 Years After Mandibular Surgery.

We demonstrate a highly reliable minimally invasive treatment for removal of residual wire from the mandible. The patient was a 55-year-old Japanese man who was referred to our department for a fistula in his submental area. The patient had undergone open reduction and fixation with wires for mandibular fractures (left parasymphysis, right angle fracture) more than 40 years prior and mandibular tooth extraction and drainage 6 months prior. Minimally invasive endoscopy-assisted wire removal surgery was performed under general anesthesia with good visualization in a narrow surgical field. Bone resection was minimized using an ultrasonic cutting instrument with a wide choice of tip shapes. The use of endoscopy with ultrasonic cutting tools makes it possible to effectively utilize narrow surgical fields with a small skin incision and minimal bone cutting. The advantages and disadvantages of the newer endoscopic systems in oral and maxillofacial surgical units are discussed.

Proposal of a new classification: "sealed type" postinfarction left ventricular free wall rupture.

OBJECTIVE: Postinfarction left ventricular free wall rupture (FWR) has been classified into blow-out type and oozing type. However, considering past papers, oozing type included the cases in which the bleeding had spontaneously stopped or sealed, and the distinction between blow-out type and oozing type was not always clear. We classified FWR into the BO type (combination of blow-out type and oozing type) with continuous bleeding and sealed type and clarified the pathophysiology of the sealed type. METHODS: Thirty-five patients who underwent surgical treatment for FWR during the past 21 years were retrospectively evaluated. RESULTS: Twenty-one patients (60%) were sealed. Comparing the sealed type with the BO type, the incidence of sudden collapse with acute onset was significantly lower (sealed type; 62%, BO type; 100%, P = 0.0118), and there were more cases of transport from outside the hospital (76%, 43%, P = 0.0453). Significantly few cases had electro-mechanical dissociation immediately before surgery (10%, 71%, P = 0.0001). In the sealed type, median sternotomy was performed in 9 patients (43%), and subxiphoid drainage was performed in 12 (57%). Fifteen patients (71%) were supported by IABP postoperatively, and re-rupture occurred in 3 patients without IABP. Long-term outcomes were significantly better in the sealed type than in the BO type. CONCLUSION: Sixty percent of postinfarction ventricular free wall rupture was the sealed type. Median sternotomy and sutureless repair with postoperative IABP support were reliable treatments. Subxiphoid drainage and strict blood pressure control with IABP may be acceptable surgical strategies in elderly, frail patients.

Brachiocephalic artery dissection is a marker of stroke after acute type A aortic dissection repair.

OBJECTIVE: Postoperative stroke is a serious unsolved complication after acute type A aortic dissection (ATAAD) repair. We investigated the incidence and risk factors of stroke, and hypothesized that dissection of supra-aortic vessels is an important risk factor of this morbidity. METHODS: Between 2012 and 2019, 202 (56% men, median age 68 years) patients with ATAAD underwent surgical repair. Clinical data, image findings, method of circulatory support, and repair technique were retrospectively investigated to explore the risk factor of postoperative stroke. RESULTS: Of the 202 patients, operative mortality was 6% and the incidence of postoperative stroke was 12% (n = 25). Brachiocephalic artery (BCA) dissection was associated with a higher risk of stroke (odds ratio, 3.89; 95% confidence interval, 1.104-13.780; p = .035) having no relation to the presence or absence of left common carotid artery dissection. Preoperative malperfusion syndrome, circulatory arrest time, isolated cerebral perfusion time, repair technique (total arch replacement), and femoral artery perfusion alone were not related to the incident rate of postoperative stroke. Stroke occurred in both hemispheres, regardless of the laterality of carotid artery dissection. CONCLUSION: BCA dissection was an independent risk factor of stroke after ATAAD repair.

Veno-arterio-pulmonary-arterial extracorporeal membrane oxygenation in descending aortic surgery.

Hypoxia during one-lung ventilation is a significant problem in descending aortic surgery via left thoracotomy. Veno-arterio-pulmonary-arterial extracorporeal membrane oxygenation (VAPa-ECMO), which consists of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and an additional arterial branch to perfuse a pulmonary artery (Pa), is useful.

Efficacy of Glutaraldehyde-Treated Leaflets for Mitral Valve Repair to Treat Active Infective Endocarditis: A Case Report.

We report the use of glutaraldehyde (GA) in a case of valve repair for mitral valve prolapse associated with active infective endocarditis. GA scrubbed at the site of infection decontaminates and reinforces infected fragile tissue, avoids excessive debridement, and strengthens the edges of valve leaflets to facilitate suturing.

Treatment of coronary malperfusion in type A acute aortic dissection.

Coronary malperfusion is one of the most dreadful complications of acute aortic dissection because it causes catastrophic acute myocardial infarction in patients who are already severely ill. Our strategy was as follows. After the administration of heparin, emergency percutaneous coronary intervention (PCI) was urgently performed at the same time as starting to prepare the operating room. A stent was then placed to cover the full length of dissected coronary artery. Patients whose cardiac function improved after successful coronary artery reperfusion were transferred to the operating room to undergo central repair surgery. If the cardiac function did not recover even after coronary reperfusion, and the patient required extracorporeal membrane oxygenation, we considered the best supportive care without performing central repair surgery. In patients with left coronary malperfusion, we believe that preoperative PCI must be performed immediately. Preoperative PCI might delay central repair surgery and potentially increase the risk of catastrophic cardiac tamponade. However, the benefit of PCI in preserving cardiac function exceeds the risk of cardiac tamponade. The indications of PCI before central repair in patients with right coronary malperfusion should be considered after assessing each patient's condition, including the presence or absence of cardiac tamponade and right ventricular infarction, left ventricular function, the immediate availability of cardiologists or cardiac surgeons, and the speed of preparing the operating room.

Synthesis and Molecular Structure of a Novel Compound Containing a Carbonate-Bridged Hexacalcium Cluster Cation Assembled on a Trimeric Trititanium(IV)-Substituted Wells-Dawson Polyoxometalate.

A novel compound containing a hexacalcium cluster cation, one carbonate anion, and one calcium cation assembled on a trimeric trititanium(IV)-substituted Wells-Dawson polyoxometalate (POM), [{Ca6(CO3)(µ3-OH)(OH2)18}(P2W15Ti3O61)3Ca(OH2)3]19- (Ca7Ti9Trimer), was obtained as the Na7Ca6 salt (NaCa-Ca7Ti9Trimer) by the reaction of calcium chloride with the monomeric trititanium(IV)-substituted Wells-Dawson POM species "[P2W15Ti3O59(OH)3]9-" (Ti3Monomer). Ti3Monomer was generated in situ under basic conditions from the separately prepared tetrameric species with bridging Ti(OH2)3 groups and an encapsulated Cl- ion, [{P2W15Ti3O59(OH)3}4{µ3-Ti(H2O)3}4Cl]21- (Ti16Tetramer). The Na7Ca6 salt of Ca7Ti9Trimer was characterized by complete elemental analysis, thermogravimetric (TG) and differential thermal analyses (DTA), FTIR, single-crystal X-ray structure analysis, and solution 183W and 31P NMR spectroscopy. X-ray crystallography revealed that the [Ca6(CO3)(µ3-OH)(OH2)18]9+ cluster cation was composed of six calcium cations linked by one µ6-carbonato anion and one µ3-OH- anion. The cluster cation was assembled, together with one calcium ion, on a trimeric species composed of three tri-Ti(IV)-substituted Wells-Dawson subunits linked by Ti-O-Ti bonds. Ca7Ti9Trimer is an unprecedented POM species containing an alkaline-earth-metal cluster cation and is the first example of alkaline-earth-metal ions clustered around a titanium(IV)-substituted POM.

Pitfalls for the "Sandwich technique" via a right ventricular incision to repair post-infarction ventricular septal defects.

BACKGROUND: We have reported "sandwich technique," via a right ventricular incision, to treat a post-infarction ventricular septal defect (VSD). This technique involves the placement of patches on both the left and right sides of the septum, pinching the VSD sealed with surgical adhesive between the two patches. In this study, we analyzed factors influencing 1-year mortality to determine the pitfalls in our procedure. METHODS: We evaluated 24 consecutive patients with post-infarction VSD who underwent the "sandwich technique" via a right ventricular incision. One-year survival and major residual leak were used as the criteria for the analysis of survival and technical success, respectively. In protocol 1, clinical variables were evaluated as predictors of one-year mortality. In protocol 2, surgical techniques were evaluated as predictors of major residual leak, which was found to be related to one-year mortality in protocol 1. RESULTS: In protocol 1, the one-year mortality was higher in patients with major residual leak (75 %, 3/4) than in those without (15 %, 3/20) (p = 0.035). In protocol 2, the patients with major residual leak had smaller patches than those without (41.9 ± 3.8 vs. 47.8 ± 4.8 mm, p = 0.031) and a smaller size difference between the patches and the VSD (22.5 ± 6.5 vs. 30.0 ± 5.7 mm, p = 0.028). CONCLUSION: For the "sandwich technique" via a right ventricular approach to treat post-infarction VSD, the choice of patch size according to VSD size is an important variable for reducing major residual leak.

Pathophysiology and Surgical Treatment of Type A Acute Aortic Dissection.

Objectives: We report the pathophysiology and treatment results of type A acute aortic dissection from our 20-year experience. METHODS: We studied 673 patients with type A acute aortic dissection who underwent initial treatment from 1994 through July 2014. We divided these patients into two groups. The former group comprised 448 patients from 1994 through 2008, and the latter group comprised 225 patients from 2009 onward, when the current strategy of initial treatment and surgical technique including the early organ reperfusion therapies were established. Results: Women were significantly often presented than men in patients over 60 years of age. Thrombosed-type dissection accounted for more than half in patients over 70 years, and significantly often complicated pericardial effusion and cardiac tamponade than patent type. Malperfusion occurred in 26% of patients. Central repair operations were performed in 579 patients. In-hospital mortality for all patients was 15%, and for the patients who underwent central repair operations was 10%. Former period of operation, malperfusion, and preoperative cardiopulmonary arrest were significant risk factor of in-hospital death. Preoperative left main trunk (LMT) stents were placed in eight patients and superior mesenteric artery (SMA) intervention was performed in five, they were effective to improve the outcome. From 2009 onward, in-hospital mortality was 5.0% and there was no significant risk factor. Conclusion: Surgical results of type A acute aortic dissection were dramatically improved in the past 20 years. Early reperfusion strategy for the patients with malperfusion improved the outcomes. (This article is a translation of Jpn J Vasc Surg 2015; 24: 127-134.).

Heparin-Induced-Thrombocytopenia Causing Massive Aortic Thrombosis after Ascending Aortic Replacement for Type A Acute Aortic Dissection.

A 77-year-old woman underwent emergency ascending aortic replacement for type A acute aortic dissection. Fifteen days after the operation, she had motor and sensory disturbances in the lower limbs. Computed tomography revealed multiple aortic thrombi and disrupted blood flow in the right external iliac and left common iliac arteries. She underwent an emergency thrombectomy for acute limb ischemia. Because heparin-induced-thrombocytopenia (HIT) was suspected to have caused the multiple aortic thrombi, we postoperatively changed the anticoagulant therapy from heparin to argatroban. Seventeen days after the first operation, gastrointestinal bleeding developed, and the patient died of mesenteric ischemia caused by HIT. Arterial embolization caused by HIT after cardiovascular surgery is a rare, but fatal event. To avoid fatal complications, early diagnosis and early treatment are essential. Use of a scoring system would probably facilitate early diagnosis.

Synthesis and Molecular Structure of a Water-Soluble, Dimeric Tri-Titanium(IV)-Substituted Wells-Dawson Polyoxometalate Containing Two Bridging (C5Me5)Rh2+ Groups.

A novel trititanium(IV)-substituted Wells-Dawson polyoxometalate (POM)-based organometallic complex, i.e., a dimeric POM containing two bridging Cp*Rh(2+) groups (Cp* = C5Me5) or [{α-P2W15Ti3O60(OH)2}2(Cp*Rh)2](16-) (D-1) with Ci symmetry, was synthesized in an analytically pure form by a 1:2 -molar ratio reaction of the organometallic precursor [Cp*RhCl2]2 with the separately prepared, monomeric trititanium(IV)-substituted Wells-Dawson POM, "[P2W15Ti3O59(OH)3](9-)" (M-1). The crystalline sample (NaK-D-1) of the water-soluble, mixed sodium/potassium salt of D-1 was obtained in the 14.7% yield, which has been characterized by complete elemental analysis, TG/DTA, FTIR, single-crystal X-ray structure analysis, and solution ((183)W, (31)P, (1)H and (13)C{(1)H}) NMR spectroscopy. Single-crystal X-ray structure analysis revealed that the two species of the protonated Wells-Dawson subunits, "[P2W15Ti3O60(OH)2](10-)" were bridged by the two Cp*Rh(2+) groups, resulting in the an overall Ci symmetry. The Cp*Rh(2+) groups were linked to the two terminal oxygen atoms of the titanium(IV) sites and one edge-sharing oxygen atom of the surface Ti-O-Ti bond. The (183)W NMR of D-1 dissolved in D2O showed that its solution structure was represented as a dimeric POM with a formula of [{α-P2W15Ti3O60(OH)3}2{Cp*Rh(OH)}2](16-) (D-2) with Ci (or S2) symmetry. A trititanium(IV)-substituted Wells-Dawson POM-supported organometallic complex has never been reported so far, and thus D-1 in the solid state and D-2 in solution are the first example of this type of complex.

[A re-do case of recurrent constrictive pericarditis 35 years after pericardiectomy; report of a case].

Reports of recurrent constrictive pericarditis are scarce. We report a re-do case of recurrent constrictive pericarditis 35 years after pericardiectomy. The calcified pericardium was thick and severely adhesive. We performed pericardiectomy on pump, using Harmonic Scalpel and rib scissors for a safe and secure operation. The calcified pericardium looked like a crab's shell. The patient was discharged on 14th post-operative day. Long-term follow-up is necessary for this patient.

Left atrium ball thrombus in a patient with hemorrhagic cerebral infarction.

The patient was a 72-year-old man with left hemiparesis. Multiple hemorrhagic cerebral infarctions were recognized on a computed tomographic (CT) scan. A transesophageal echocardiogram showed a huge left atrial mass, which was floating and nearly obstructed the mitral orifice in the diastolic phase. Emergency left atrial mass removal was performed. To reduce the risk of critical brain hemorrhage, the dose of heparin was reduced (100 U/kg) and 1 mg/kg/h of nafamostat mesilate was administered into the venous circuit during extracorporeal circulation. A postoperative brain CT scan showed no evidence of deterioration of cerebral hemorrhage. Pathologic examination showed a ball thrombus.

Partial translocation mitral valve replacement with autologous pericardial patch reinforcement of ventricularized left atrial wall for severe annular calcification extending to the left ventricle.

We describe a technique of partial translocation with an autologous pericardial patch reinforcement of the left atrial wall in patients with extensive mitral annular calcification (MAC) who require mitral valve replacement.

In situ graft replacement and rectus abdominis muscle flap transfer for infected thoracoabdominal aortic aneurysm after gastrectomy.

An infected thoracoabdominal aneurysm is a rare, life-threatening condition with high mortality. We performed an in situ graft replacement and applied a rectus abdominis muscle flap transfer technique in a case of infected thoracoabdominal aortic aneurysm after distal gastrectomy. A rectus abdominis muscle flap transfer might be a good alternative when the omental flap technique is not feasible.

Encapsulation of anion/cation in the central cavity of tetrameric polyoxometalate, composed of four trititanium(IV)-substituted α-Dawson subunits, initiated by protonation/deprotonation of the bridging oxygen atoms on the intramolecular surface.

Preparation and structural characterization of a novel polyoxometalate (POM), [(P(2)W(15)Ti(3)O(60.5))(4)(NH(4))](35-) 1, i.e., an encapsulated NH(4)(+) cation species in the central cavity of a tetramer (called the Dawson tetramer) constituted by trititanium(IV)-substituted α-Dawson POM substructure, are described. POM 1 was synthesized by several different methods and unequivocally characterized by complete elemental analysis, thermogravimetric and differential thermal analysis (TG/DTA), FTIR spectroscopy, solution ((15)N{(1)H}, (31)P, (183)W) NMR spectroscopy, and X-ray crystallography. First, POM 1 was synthesized by a reaction of NH(4)Cl in aqueous solution with a precursor, which was derived by thermal treatment of a monomeric triperoxotitanium(IV)-substituted Dawson POM, [α-1,2,3-P(2)W(15)(TiO(2))(3)O(56)(OH)(3)](9-) 2, for 3 h in an electric furnace at 200 °C. The encapsulated NH(4)(+) cation in 1 was confirmed by (15)N{(1)H} NMR measurement and X-ray crystallography. As another synthesis of 1, a direct exchange of the Cl(-) anion encapsulated in [{α-1,2,3-P(2)W(15)Ti(3)O(57.5)(OH)(3)}(4)Cl](25-) 3 with the NH(4)(+) cation was attained by neutralizing an aqueous solution containing 3 with the addition of aqueous NH(3) (the initial pH of ca. 2-2.5 was changed to 6.4), followed by adding NH(4)Cl. It has been clarified that the conditions as to whether the anion or the cation is encapsulated in the central cavity of the Dawson tetramer were significantly related to the protonation/deprotonation of the bridging oxygen atoms on the intramolecular surface, Ti-O-Ti/Ti-OH-Ti sites constituting the Dawson subunits.

[Usefulness of photo dynamic eye system for detection of graft spasm in off-pump coronary artery bypass grafting].

A 54-year-old-man on hemodialysis was admitted to the hospital because of effort angina. A coronary angiography revealed multiple stenoses including 90% stenosis in the left main trunk. Coronary artery bypass grafting (CABG) was performed with Y-composite grafts constructed by the right internal thoracic artery (RITA) and the free gastroepiploic artery (GEA) which were anastomosed to left anterior descending artery (LAD) and the diagonal branch (D1) using the off-pump technique. After completion of anastomosis, Photo Dynamic Eye (PDE) system showed fluorescence not in the free GEA but at the anastomotic site of GEA to D1. Because the graft spasm of GEA was diagnosed by PDE, papaverine solution was sprayed to the graft, which resolved the spasm and re-anastomosis was avoided. PDE system is a useful tool for the diagnosis of graft spasm, and may contribute to improvement of quality of CABG.