New regional drug delivery system by direct epicardial placement of slow-release prostacyclin agonist promise therapeutic angiogenesis in a porcine chronic myocardial infarction.

Although prostacyclin is an endogenous factor for the protection and regeneration of damaged tissue, the use of clinically available prostacyclin analogues for treating chronic pathological conditions is limited owing to their short half-lives. A new reagent, ONO-1301SR, which is a unique synthetic prostacyclin agonist polymerized with lactic and glycolic acid, has been demonstrated to constitutively release prostacyclin analogues to adjacent tissues, suggesting its therapeutic potential via slow-release delivery into a specific organ. In this study, we investigated the regenerative effect of direct epicardial delivery of the ONO-1301SR on a heart with a chronic myocardial infarct. An ameroid constrictor was placed on the left anterior descending coronary artery of Göttingen minipigs for 4 weeks to induce ischemic cardiomyopathy; this was followed by direct epicardial placement of ONO-1301SR-immersed gelatinous sheet, or only a gelatinous sheet on the anterolateral surface of the heart. Epicardial placement of ONO-1301SR resulted in significant recovery of global cardiac functions and regional wall motion of the lateral wall. Importantly, after epicardial placement of ONO-1301SR for 4 weeks, the myocardial blood flow significantly increased in the lateral region as assessed by 13N-ammonia positron emission tomography; this finding was consistent with significantly increased capillary density in the peri-infarct area with up-regulated angiogenic cytokine expression. Conclusion: Use of the slow-release drug delivery system of prostacyclin agonist yielded regenerative angiogenesis, including increased regional blood perfusion and systolic function in a porcine model of chronic myocardial infarction.

A Rare Case of Chronic Expanding Intrapericardial Hematoma with Refractory Right-sided Heart Failure 30 Years after the Surgical Repair of Tetralogy of Fallot.

We herein report the case of a 79-year-old man who presented with right-sided heart failure (HF) 27 years after undergoing surgery for tetralogy of Fallot. The HF did not respond well to oral diuretics. Transthoracic echocardiography and chest X-ray failed to determine the cause of the HF for three years. An intrapericardial mass located just behind the sternum, was finally identified on computed tomography. The mass had compressed the right ventricle, causing right-sided HF. Pre-surgical diagnostic images led to suspicion of a chronic expanding intrapericardial hematoma (CEIH), and the CEIH was surgically removed. The patient's symptoms improved markedly.

Successful surgical case of refractory chronic expanding intrapericardial hematoma treated with preoperative coil embolization of the feeding vessels.

Complete surgical resection of chronic expanding intrapericardial hematoma was often difficult because of the severe adhesion. Preoperative coil embolization of the feeding vessels can prevent recurrent expanding of the residual hematoma and would achieve good results.

3D-printed aortic stenosis model with fragile and crushable calcifications for off-the-job training and surgical simulation.

Surgical simulation devices can be helpful and cost-effective adjuncts to on-the-job training. In this tutorial we present our method for creating an aortic stenosis model with realistically fragile and crushable calcifications, using modern 3D-printing techniques.  The model can be used for training and surgical simulation and is an effective aid to learning for young cardiovascular surgeons.

Vessel Stretching Is a Cause of Lumen Enlargement Immediately After Balloon Pulmonary Angioplasty: Intravascular Ultrasound Analysis in Patients With Chronic Thromboembolic Pulmonary Hypertension.

BACKGROUND: Balloon pulmonary angioplasty (BPA) has become an alternative therapy for patients with chronic thromboembolic pulmonary hypertension who are ineligible for pulmonary endarterectomy. We retrospectively investigated intravascular ultrasound measurements to elucidate how the lumen enlarges immediately after BPA. METHODS AND RESULTS: A total of 326 lesions in 71 patients with chronic thromboembolic pulmonary hypertension were analyzed. The cross-sectional areas (CSAs) of the external elastic membrane and lumen measured by intravascular ultrasound before and after BPA were assessed for each lesion type (type A, ring-like stenosis lesions; type B, web lesions; type C, subtotal occlusion lesions). Comparing the lesion types, the proportion of the area occupied by fibrous tissue was smallest in the type A lesions and largest in the type C lesions. The mean lesion lumen CSA was increased after BPA because of an increase in external elastic membrane CSA (from 23.2±12.9 to 27.2±14.3 mm2; P<0.001) with a slight decrease in fibrous tissue plus media CSA (from 17.7±11.7 to 17.3±11.1 mm2; P<0.001). The change in lumen CSA correlated strongly with the change in external elastic membrane CSA (r2=0.762; P<0.001). CONCLUSIONS: Lumen enlargement immediately after BPA was obtained by the overall vessel expansion induced by a stretch of the arterial wall. In addition, the amount of fibrous tissue depended on each lesion type. Thus, it might be beneficial to change the balloon size to correspond with the lesion type.

To what extent can 3D model replicate dimensions of individual mitral valve prolapse?

Determining the complex geometry of mitral valve prolapse is often difficult. We constructed 3D models of six prolapsed mitral valves for surgical assessment, and evaluated how accurately the models could replicate individual valve dimensions. 3D polygon data were constructed based on an original segmentation method for computed tomography images. The model's replication performance was confirmed via dimensional comparison between the actual hearts during surgery and those models. The results revealed that the prolapsed segments matched in all cases; however, torn chordae were replicated in four cases. The mean height differences were 0.0 mm (SD 1.6, range - 2 to + 2 mm) for the anterolateral side, 0.0 mm (SD 1.7, range - 2 to + 2 mm) for the prolapsed leaflet center, and - 1.5 mm (SD 0.6, range - 1 to - 2 mm) for the posteromedial side. Regression analysis showed a strong and positive correlation, and Bland-Altman plots indicated quantitative similarity of the models to the actual hearts. We concluded that our 3D valve models could replicate the actual mitral valve prolapses within acceptable dimensional differences. Our concepts are useful for better 3D valve creation and better surgical planning with reliable 3D valve models.

[Splenic Artery Left Common Iliac Artery Bypass for Hepatocellular Carcinoma with Celiac Artery Compression Syndrome - A Case Report].

Celiac artery compression syndrome(CACS)is a rare disorder characterized by postprandial intestinal angina caused by insufficient blood supply to the gastrointestinal organs. In this syndrome, the root of the celiac artery is compressed and narrowed by the median arcuate ligament of the diaphragm during expiration, sometimes causing difficulties in trans-arterial intervention. We report here a case that trans-hepatic arterial intervention was able to performed by splenic bypass. A 74- year-old man with multiple hepatocellular carcinoma(HCC)was performed the angiography, and diagnosed as CACS due to celiac artery root obstruction. The median arcuate ligament was incised in order to introduce trans-arterial intervention, but sufficient resumption of blood flow in the root of celiac artery could not be obtained, so bypass surgery was added from left common iliac artery to splenic artery with grafted right saphenous vein. One month later, trans hepatic arterial intervention is performed via graft, and treatment of HCC is ongoing. Splenic artery left common iliac artery bypass surgery was also considered to be an option for cases in which the resurgence of the blood flow in the root of the celiac artery was not obtained even in the median arcuate ligament dissection for CACS.

Novel Angiographic Classification of Each Vascular Lesion in Chronic Thromboembolic Pulmonary Hypertension Based on Selective Angiogram and Results of Balloon Pulmonary Angioplasty.

BACKGROUND: Balloon pulmonary angioplasty (BPA) is an alternative therapy for patients with chronic thromboembolic pulmonary hypertension who are ineligible for standard therapy, pulmonary endarterectomy. Although there are several classifications of vascular lesions, these classifications are based on the features of the specimen removed during pulmonary endarterectomy. Because organized thrombi are not removed during balloon pulmonary angioplasty, we attempted to establish a new classification of vascular lesions based on pulmonary angiographic images. We evaluated the success and complication rate of BPA in accordance with the location and morphology of thromboembolic lesions. METHODS AND RESULTS: We reviewed 500 consecutive procedures (1936 lesions) of BPA in 97 patients with chronic thromboembolic pulmonary hypertension and investigated the outcomes of BPA based on the lesion distribution and the angiographic characteristics of the thromboembolic lesions, as follows: type A, ring-like stenosis lesion; type B, web lesion; type C, subtotal lesion; type D, total occlusion lesion, and type E, tortuous lesion. The success rate was higher, and the complication rate was lower in ring-like stenosis and web lesions. The total occlusion lesions had the lowest success rate. Tortuous lesions were associated with a high complication rate and should be treated only by operators with extensive experience with BPA. CONCLUSIONS: We modified the previous angiographic classification and established a new classification for each vascular lesion. We clarified that the outcome and complication rate of the BPA are highly dependent on the lesion characteristics.

Morphological analysis and preoperative simulation of a double-chambered right ventricle using 3-dimensional printing technology.

We present a case of a double-chambered right ventricle in adulthood, in which we tried a detailed morphological assessment and preoperative simulation using 3-dimensional (3D) heart models for improved surgical planning. Polygonal object data for the heart were constructed from computed tomography images of this patient, and transferred to a desktop 3D printer to print out models in actual size. Medical staff completed all of the work processes. Because the 3D heart models were examined by hand, observed from various viewpoints and measured by callipers with ease, we were able to create an image of the complete form of the heart. The anatomical structure of an anomalous bundle was clearly observed, and surgical approaches to the lesion were simulated accurately. During surgery, we used an incision on the pulmonary infundibulum and resected three muscular components of the stenosis. The similarity between the models and the actual heart was excellent. As a result, the operation for this rare defect was performed safely and successfully. We concluded that the custom-made model was useful for morphological analysis and preoperative simulation.

Pulmonary microvascular remodeling after balloon pulmonary angioplasty in a patient with chronic thromboembolic pulmonary hypertension.

We herein report a case of peripheral type chronic thromboembolic pulmonary hypertension treated with medical therapy and subsequent balloon pulmonary angioplasty (BPA). After a series of BPA procedures, the patient's hemodynamics almost completely normalized. The patient was later diagnosed with lung carcinoma, and the vasculature of the resected lung demonstrated intimal thickening and luminal stenosis in the pulmonary arteries in both the areas where BPA was performed and not performed, in spite of a marked reduction in pulmonary arterial pressure. The present case is the first report on the histology of the pulmonary vasculature following BPA.

Quadricuspid aortic valve complicated with infective endocarditis: report of a case.

Congenital quadricuspid aortic valve is a rare cardiac malformation with an unknown risk of infective endocarditis. We report a case of quadricuspid aortic valve complicated with infective endocarditis. A 53-year-old Japanese woman was hospitalized with leg edema and a fever of unknown origin. Corynebacterium striatum was detected in the blood culture. Echocardiography demonstrated a quadricuspid aortic valve with vegetation and severe functional regurgitation. The condition was diagnosed as a quadricuspid aortic valve with infective endocarditis, for which surgery was performed. The quadricuspid aortic valve had three equal-sized cusps and one smaller cusp (type B according to Hurwitz classification). We dissected the vegetation and infectious focus and implanted a mechanical valve. Following the case report, we review the literature.

Abdominal aortic aneurysmal and endovascular device infection with iliopsoas abscess caused by Mycobacterium bovis as a complication of intravesical bacillus Calmette-Guérin therapy.

Vascular complications after the intravesical instillation of Bacillus Calmette-Guérin (BCG) therapy are extremely rare. We experienced a case of abdominal aortic aneurysmal infection excluded by a stent graft with an iliopsoas abscess after intravesical instillation of BCG therapy that required reoperation. Five years ago, an 81-year-old man was diagnosed with transitional cell carcinoma of the bladder. After transurethral resection of the bladder tumor and intravesical BCG therapy, a radical cystectomy was performed. Twenty-four months after intravesical BCG therapy, follow-up an abdominal computed tomographic (CT) scan revealed an aortic abdominal aneurysm. Endovascular aneurysm repair was performed, and the aneurysm was excluded postoperatively. Thirty months after the endovascular aneurysm repair (and 54 months after intravesical BCG therapy), a follow-up abdominal CT revealed a low-density area in the right iliopsoas muscle that formed a fistula to the excluded aneurysm. We performed CT-guided iliopsoas abscess drainage and collected yellow pus. Polymerase chain reaction analysis revealed that the pus was positive for Mycobacterium tuberculosis complex. The patient was diagnosed with abdominal aortic aneurysmal infection associated with iliopsoas abscess caused by Mycobacterium bovis, and surgery was performed. We performed an extra-anatomical bypass and removed the stent graft with debridement. When the aneurysmal wall was incised and resected, yellow pus surrounded the stent graft. In addition, a large fistula was present between the right posterolateral aortic aneurysmal wall and the iliopsoas abscess cavity. After the operation, the histopathological examination of excised abdominal aortic aneurysmal wall tissue revealed an epithelioid granuloma with caseous necrosis involving multinucleated giant cells, indicating M tuberculosis complex infection. Although the intravesical instillation of BCG therapy is considered safe, complications resulting from vascular infections can arise in extremely rare cases. The complication described in this case report emphasizes the need to cautiously select treatment for a mycotic aortic aneurysm after intravesical instillation of BCG therapy.

Thoracic aortic aneurysm with aortic pseudocoarctation involving the left subclavian artery.

A 39-year-old man with a thoracic aortic aneurysm and pseudocoarctation underwent graft replacement of the distal arch. The left subclavian artery, which rose just after the aneurysm, was also reconstructed at surgery. The aneurysmal wall was extremely thin, and the adventitia and a small amount of medial tissue were found on histologic examination. Thus, surgical treatment was recommended due to risk of rupture. Furthermore, because aneurysms involved the cervical branch, separate reconstruction was also performed. Endovascular intervention is not appropriate for this group of patients because of the complex kinking of the aorta and the extremely thin aneurysmal wall.

Mid-term results of small-sized St. Jude Medical Regent prosthetic valves (21 mm or less) for small aortic annulus.

Prosthesis-patient mismatch (PPM) is always of concern when performing aortic valve replacement (AVR) in patients with a small aortic annulus. Although bioprosthetic AVR is preferred in patients older than 65 years, we have experienced cases in elderly patients with a small aortic annulus whereby we could not implant small-sized bioprosthetic valves. We have implanted St. Jude Medical Regent (SJMR) mechanical valves (St. Jude Medical, St. Paul, MN, USA) as necessary, even in elderly patients with no aortic annulus enlargement. We investigated our experiences of AVR with SJMR mechanical valves of 21 mm or less in size. Between January 2006 and December 2009, 40 patients underwent AVR with SJMR mechanical valves ≤21 mm in size: 9 patients received 21-mm valves, 19 received 19-mm valves, and 12 received 17-mm valves. The mean age was 65.9 ± 9.5 years, and 25 patients (62.5 %) were 65 years or older. We evaluated the clinical outcome and the echocardiographic data for each valve size. There was no operative or hospital mortality. The mean duration of clinical follow-up was 31.2 ± 17.6 months. During follow-up, there were no hospitalizations due to heart failure. The cumulative valve-related event-free survival was 93 % at 33 months, and the cumulative hemorrhagic event-free survival was 93 % at 33 months and 84 % at 43 months, using the Kaplan-Meier method. At follow-up, the mean values of the measured effective orifice area (EOA) for the 21-, 19-, and 17-mm prostheses were 2.00 ± 0.22, 1.74 ± 0.37, and 1.25 ± 0.26 cm(2), and the mean measured EOA index (EOAI) were 1.17 ± 0.12, 1.11 ± 0.21 and 0.90 ± 0.22 cm(2)/m(2), respectively. A PPM (EOAI ≤0.85) was documented in 5 patients, all of whom had received a 17-mm SJMR valve. AVR with SJMR valves of 21 mm or less in size appears to show satisfactory clinical and hemodynamic results.

Refined balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension.

BACKGROUND: Although balloon pulmonary angioplasty (BPA) for inoperable patients with chronic thromboembolic pulmonary hypertension was first reported over a decade ago, its clinical application has been restricted because of limited efficacy and complications. We have refined the procedure of BPA to maximize its clinical efficacy. METHODS AND RESULTS: Sixty-eight consecutive patients with inoperable chronic thromboembolic pulmonary hypertension underwent BPA. We evaluated pulmonary artery diameters and determined the appropriate balloon size by using intravascular ultrasound. We performed BPA in a staged fashion over multiple, separate procedures to maximize efficacy and reduce the risk of reperfusion pulmonary injury. A total of 4 (2-8) sessions were performed in each patient, and the number of vessels dilated per session was 3 (1-14). The World Health Organization functional class improved from 3 to 2 (P<0.01), and mean pulmonary arterial pressure was decreased from 45.4 ± 9.6 to 24.0 ± 6.4 mm Hg (P<0.01). One patient died because of right heart failure 28 days after BPA. During follow-up for 2.2 ± 1.4 years after the final BPA, another patient died of pneumonia, and the remaining 66 patients are alive. In 57 patients who underwent right heart catheterization at follow-up, improvement of mean pulmonary arterial pressure was maintained (24.0 ± 5.8 mm Hg at 1.0 ± 0.9 years). Forty-one patients (60%) developed reperfusion pulmonary injury after BPA, but mechanical ventilation was required in only 4 patients. CONCLUSIONS: Our refined BPA procedure improves clinical status and hemodynamics of inoperable patients with chronic thromboembolic pulmonary hypertension, with a low mortality. A refined BPA procedure could be considered as a therapeutic approach for patients with inoperable chronic thromboembolic pulmonary hypertension.

Acute vasoreactivity testing with nicardipine in patients with pulmonary arterial hypertension.

Acute vasoreactivity testing for patients with pulmonary arterial hypertension (PAH) has been reported to be useful to identify patients with sustained beneficial response to oral calcium-channel blockers (CCBs), but there is a risk of exacerbation during the testing with oral CCBs. Therefore, we developed a testing method utilizing intravenous nicardipine, a short-acting CCB, and examined the safety and usefulness of acute vasoreactivity testing with nicardipine in PAH patients. Acute vasoreactivity testing with nicardipine was performed in 65 PAH patients. Nicardipine was administered by short-time continuous infusion (1 µg·kg⁻¹·min⁻¹ for 5 min and 2 µg·kg⁻¹·min⁻¹ for 5 min) followed by bolus injection (5 µg/kg). Hemodynamic responses were continuously measured using a right heart catheter. Acute responders were defined as patients who showed a decrease in mean pulmonary artery pressure of at least 10 mmHg to an absolute level below 40 mmHg with preserved or increased cardiac output. Two acute responders and sixty-three non-acute responders were identified. There was no hemodynamic instability requiring additional inotropic agents or death during the testing. Acute responders had good responses to long-term oral CCBs. The acute vasoreactivity testing with nicardipine might be safe and useful for identifying CCB responders in PAH patients.

Two cases of transthoracic pericardial fenestration for pericardial effusion.

Pericardial effusion and cardiac tamponade are often refractory and difficult to manage. The transthoracic pericardial fenestration which create a window is the conventional procedure for releasing pericardial effusion to the thoracic cavity. We experienced two cases of pericardial fenestration. The first case was a patient with hypertrophic cardiomyopathy with pericardial effusion. She had a thoracic compression fracture, which indicated pericardial fenestration before an orthopedic surgery. The second case was a patient with recurrent cardiac tamponade caused by postpericardiotomy syndrome after off-pump coronary artery bypass grafting. In both cases, the patients underwent left anterior thoracotomy of about 10 cm at the level of the 5th intercostal space. The pericardium was incised within a radius of about 20 mm; furthermore, the fenestrated window was opened to the left thoracic cavity. In this paper, we present our experience of pericardial fenestration and discuss a review of the literature.

Primary echocardiographic results of the Carpentier-Edwards Perimount Magna.

PURPOSE: The aim of this study was to investigate the primary echocardiographic results of aortic valve replacement using 21- and 19-mm Carpentier-Edwards Perimount Magna bioprosthesis aortic xenografts in patients with small aortic annulus. METHODS: Twenty patients (mean body surface area 1.63 ± 0.16 m(2)) underwent aortic valve replacement between June 2008 and December 2009. Eight and 12 patients received 21- and 19-mm Magna bioprostheses, respectively. After 12 months, hemodynamic data were obtained by echocardiography to estimate the prosthesis-patient mismatch. RESULTS: At follow-up, significant decreases in peak and mean left ventricular aortic pressure gradients were observed in the 12 patients with aortic stenosis (P < 0.05). Regression of the left ventricular mass was observed in all the patients (P < 0.05). The mean measured effective orifice area (EOA) and EOA index (EOAI) were 1.61 ± 0.28 cm(2) and 0.99 ± 0.16 cm(2)/m(2), respectively. Prosthesis-patient mismatch (EOAI ≤0.85) was documented in three patients. CONCLUSION: The primary echocardiographic findings suggested that the hemodynamic performance of the 19- and 21-mm Carpentier-Edwards Perimount Magna bioprostheses was satisfactory in the patients with a small aortic annulus.

Surgical reconstruction for intrathoracic aneurysm originating from proximal part of the right subclavian artery.

Subclavian artery aneurysms are comparatively rare in peripheral aneurysms. We experienced a case of intrathoracic aneurysm originating from the proximal part of the right subclavian artery. A 78 year-old man was referred to our hospital with the diagnosis of a right subclavian artery aneurysm. Enhanced computed tomography demonstrated an intrathoracic aneurysm, originating from the right subclavian artery just proximal of its origin. Through a median sternotomy and supra-infraclavicular incision, we reconstructed the brachiocephalic and right common carotid arteries and bypassed to the distal part of the right subclavian artery by using a T-shaped vascular graft and the aneurysm was excluded.