[Long-term Outcomes of the Maze Procedure Omitting the Ablation Line to The Superior Vena Cava].

OBJECTIVE: In an effort to avoid postoperative sick sinus syndrome( SSS), we omit the ablation line to the superior vena cava( SVC) in the Cox-mazeⅢ lesion set. We report the long-term outcomes, including the freedom from SSS. METHODS: We studied 102 patients who underwent bi-atrial maze procedure for persistent atrial fibrillation (Af) from 2009 through 2023. Bipolar radio frequency ablation or cryoablation was used except for right-side atriotomy and right atriotomy. Cryoablation was used for atrioventricular annulus. The patient age was 68±9.4. Duration of Af was 3.4±6.5 years (unknown 9 cases). The amplitude of f-wave in V1 was 0.182±0.095 mV and it was<0.1 mV in 19 (18.6%). Diameter of the left atrium was 50±8.9 mm, and left atrial volume index was 89±37 ml/m2. Ninety-one (89.2%) patients underwent concomitant mitral valve surgery. RESULTS: Survival rate was 99% at 1 year and 96% at 5 years. Freedom from Af was 92% at 1 year and 88% at 5 years. Freedom from permanent pacemaker implantation (PPI) was 87% at 1 year and 83% at 5 years. CONCLUSIONS: Defibrillation rate and the incidence of PPI was comparable to those in previous reports after standard Cox-mazeⅢ. SSS after maze for persistent Af seem due to patient.

Intrapulmonary solitary fibrous tumor with malignant potential: A case report.

Intrapulmonary solitary fibrous tumor is rare, and its clinical course has not been sufficiently reported. We presented a case of an 80-year-old male non-smoker and discussed the surgical procedure selection and the recurrence risk assessment. A solid nodule, 1.1 cm in diameter, was identified in the left lower lobe on chest computed tomography and showed no accumulation on positron emission tomography. A wedge resection with a sufficient surgical margin under video-assisted thoracoscopic surgery was performed. Based on histological morphology and immunohistochemical examination, this case was considered an intrapulmonary solitary fibrous tumor with malignancy potential, requiring cautious follow-up observation.

Internal circular suture annuloplasty for aortic valve repair.

Stabilizing the aorto-ventricular junction is integral in aortic valve repair. We report our technique of internal circular suture annuloplasty. We used a continuous horizontal mattress suture of a single thick expanded polytetrafluoroethylene suture (CV-3). We put 4 stitches per sinus, so the suture was below the cusp attachment line at the nadirs and passed through the interleaflet triangle at the upper aorto-ventricular junction level. The suture was reinforced with pericardial pledgets on both sides of each commissure. We used this technique in 12 patients. The diameter of aorto-ventricular junction was reduced from 25 ± 2 mm to 22 ± 1 mm (n = 11) and was 22 ± 1 mm at the latest follow-up (4-74 months, median 41, n = 10). In 2 patients with large aorto-ventricular junction (27 mm or more), expected annular reduction was not achieved. Our modified technique is simple and seems durable. It may be useful for mild annular dilatation.

[Prevention and Treatment of Ischemic Spinal Cord Injury].

In recent years, the widespread use of thoracic/thoracoabdominal stent grafting and a better understanding of spinal cord blood supply have led to quite a few change in measures to prevent spinal cord injury. It is essential to understand the characteristics of spinal cord blood flow, which is complicated by collateral pathways, and to strive to maintain spinal cord blood flow during surgery. It is also important to plan staged repair as much as possible in any treatment modality. Particular attention must be paid to the prevention of second attacks, especially after thoracic/thoracoabdominal endovascular aortic repair without segmental artery reconstruction. Systemic circulatory and respiratory management, improvement of anemia, and cerebrospinal fluid drainage with attention to drainage rates, may be effective as preventive and therapeutic measures for spinal cord injury.

Lung adenocarcinoma and squamous cell carcinoma difficult for immunohistochemical diagnosis can be distinguished by lipid profile.

In patients with unresectable non-small cell lung cancer, histological diagnosis is frequently based on small biopsy specimens unsuitable for histological diagnosis when they are severely crushed and do not retain their morphology. Therefore, establishing a novel diagnostic method independent of tissue morphology or conventional immunohistochemistry (IHC) markers is required. We analyzed the lipid profiles of resected primary lung adenocarcinoma (ADC) and squamous cell carcinoma (SQCC) specimens using liquid chromatography-tandem mass spectrometry. The specimens of 26 ADC and 18 SQCC cases were evenly assigned to the discovery and validation cohorts. Non-target screening on the discovery cohort identified 96 and 13 lipid peaks abundant in ADC and SQCC, respectively. Among these 109 lipid peaks, six and six lipid peaks in ADC and SQCC showed reproducibility in target screening on the validation cohort. Finally, we selected three and four positive lipid markers for ADC and SQCC, demonstrating high discrimination abilities. In cases difficult to diagnose by IHC staining, [cardiolipin(18:2_18:2_18:2_18:2)-H]- and [triglyceride(18:1_17:1_18:1) + NH4]+ showed the excellent diagnostic ability for ADC (sensitivity: 1.00, specificity: 0.89, accuracy: 0.93) and SQCC (sensitivity: 0.89, specificity: 0.83, accuracy: 0.87), respectively. These novel candidate lipid markers may contribute to a more accurate diagnosis and subsequent treatment strategy for unresectable NSCLC.

Lipidomics-based tissue heterogeneity in specimens of luminal breast cancer revealed by clustering analysis of mass spectrometry imaging: A preliminary study.

Cancer tissues reflect a greater number of pathological characteristics of cancer compared to cancer cells, so the evaluation of cancer tissues can be effective in determining cancer treatment strategies. Mass spectrometry imaging (MSI) can evaluate cancer tissues and even identify molecules while preserving spatial information. Cluster analysis of cancer tissues' MSI data is currently used to evaluate the phenotype heterogeneity of the tissues. Interestingly, it has been reported that phenotype heterogeneity does not always coincide with genotype heterogeneity in HER2-positive breast cancer. We thus investigated the phenotype heterogeneity of luminal breast cancer, which is generally known to have few gene mutations. As a result, we identified phenotype heterogeneity based on lipidomics in luminal breast cancer tissues. Clusters were composed of phosphatidylcholine (PC), triglycerides (TG), phosphatidylethanolamine, sphingomyelin, and ceramide. It was found that mainly the proportion of PC and TG correlated with the proportion of cancer and stroma on HE images. Furthermore, the number of carbons in these lipid class varied from cluster to cluster. This was consistent with the fact that enzymes that synthesize long-chain fatty acids are increased through cancer metabolism. It was then thought that clusters containing PCs with high carbon counts might reflect high malignancy. These results indicate that lipidomics-based phenotype heterogeneity could potentially be used to classify cancer for which genetic analysis alone is insufficient for classification.

Neurofibroma with adenosis in the mammary gland: a case report.

BACKGROUND: Neurofibroma of the breast is extremely rare, with only a few reported cases. Here, we report a case of solitary neurofibroma of the breast in a 95-year-old woman. CASE PRESENTATION: A 95-year-old woman presented with a palpable mass in the left breast. Mammography revealed a well-defined mass. A 1.6-cm round mass was found in the lower outer quadrant of the left breast on ultrasonography. The internal echo of the tumor was a mixture of relatively uniform hypoechoic areas with posterior enhancement and heterogeneous hyperechoic areas. She underwent a core needle biopsy. The pathological findings revealed a spindle cell lesion with no malignant findings. At 2 months follow-up, repeat breast ultrasonography showed that the mass had enlarged to be 2.7 cm in size. A repeat core needle biopsy, however, revealed no particularly new information. Because the tumor was growing and a definite diagnosis was not made, lumpectomy was performed. We found bland-spindled cells with shredded-carrot collagen bundles. Immunohistochemical antibody markers (S100, SOX10, and CD34) were positive for the spindle cells. Some of the tumors maintained the bilayer nature of luminal cells and myoepithelial cells, which might be the reason for internal heterogeneity on ultrasound. A histological diagnosis of neurofibroma with adenosis was made. At 6 months follow-up, no recurrent lesions were found. CONCLUSIONS: Ultrasound and pathological images revealed an extremely rare case of neurofibroma combined with adenosis. Tumor resection was performed because it was difficult to make a definitive diagnosis using needle biopsy. Even when a benign tumor is suspected, short-term follow-up is necessary, and if an enlargement is observed, early tumor resection is recommended.

Multicenter Study of Surgical Ablation for Atrial Fibrillation in Aortic Valve Replacement.

There is controversy regarding appropriate surgical ablation procedures concomitant with nonmitral valve surgery. We retrospectively investigated the impact of surgical ablation for atrial fibrillation during aortic valve replacement between 2010 and 2015 in 16 institutions registered through the Japanese Society for Arrhythmia Surgery. Clinical data of 171 patients with paroxysmal and nonparoxysmal atrial fibrillation undergoing aortic valve replacement were collected and classified into full maze operation (n = 79), pulmonary vein isolation (PVI) (n = 56), and no surgical ablation (n = 36) groups. All patients were followed up and electrocardiograms were recorded in 68% at 2 years. The myocardial ischemia time was significantly longer in the maze group than the others during isolated aortic valve replacement (p ≤ 0.01), but there were no significant differences in 30-day or 2-year mortality rates between groups. The ratios of sinus rhythm at 2 years in paroxysmal and nonparoxysmal atrial fibrillation in the maze group versus PVI group were 87% versus 97%, respectively (p = 0.24) and 53% versus 42%, respectively (p = 0.47). No patients with nonparoxysmal atrial fibrillation in the no surgical ablation group maintained sinus rhythm at 2 years. In conclusion, both maze and PVI during aortic valve replacement are valuable strategies to restore sinus rhythm at 2 years and result in favorable early and midterm survival rates.

Improved complete portal 4-port robotic lobectomy for lung cancer: Hamamatsu Method KAI.

Robot-assisted thoracoscopic surgery (RATS) has been widely used in lung cancer surgery. We previously devised a new port arrangement for RATS for lung cancer, the "Hamamatsu Method", to provide good cranial field of view using the da Vinci Xi surgical system. Our method utilizes four robot ports and one assist port, while our video-assisted thoracoscopic lobectomy technique is performed with four ports. We believe the number of ports in robotic lobectomy should not exceed those in video-assisted thoracoscopic lobectomy to preserve the advantage of minimal invasiveness. Furthermore, patients are generally more sensitive to wound size and number than surgeons assume. Thus, by combining the access and camera ports of the "Hamamatsu Method", we devised the 4-port "Hamamatsu Method KAI", which is equivalent to the conventional 5-port method, while maintaining full functionality of all four robotic arms and the assistant. "Hamamatsu Method KAI" showed comparable safety as the conventional 5- or 6-port method. Our improved 4-port method ensures minimal invasiveness while maintaining the same feasibility as the original method. The novelty of this operative method is the combined camera/assistant/access incision, and this technique is an option for RATS for lung cancer. "KAI" is a Japanese suffix indicating a sequel or successor.

Blood flow characteristics of the bilateral internal thoracic artery: implications of optimal graft configuration for coronary artery bypass grafting to maximize blood supply.

PURPOSE: There is controversy regarding which internal thoracic artery (ITA) should be anastomosed to the left anterior descending artery (LAD). Here, we propose an optimal graft design based on measurement of blood flow in the ITA. METHODS: Sixty-one patients (53 men, median age 68 [62-75] years) undergoing first elective coronary artery bypass grafting were enrolled. Fifty-seven left ITAs (LITAs) and 28 right ITAs (RITAs) were harvested in either a semi-skeletonized manner using a harmonic scalpel covered with papaverine-soaked gauze (group-A, n = 45) or a fully skeletonized manner using electrocautery with intraluminal papaverine injection (group-B, n = 41). Free flow of 33 ITAs was measured after pharmacological dilatation and in situ ITA-LAD flow was measured in 59 patients by transit-time flowmetry. RESULTS: RITA and LITA free flow were 147.0 [87.8-213.0] mL/min and 108.0 [90.0-144.0] mL/min, respectively (P = 0.199). The group-B had significantly higher ITA free flow (135.0 [102.0-171.0] mL/min) than group-A (63.0 [36.0-96.0] mL/min, P = 0.009). In 13 patients with bilateral ITA harvesting, free flow of the RITA (138.0 [79.5-204.0] mL/min) was also significantly higher than the LITA (102.0 [81.0-138.0] mL/min, P = 0.046). There was no significant difference between RITA and LITA flow anastomosed to the LAD. The group-B had significantly higher ITA-LAD flow (56.5 [32.3-73.6] mL/min) than group-A (40.9 [20.1-53.7] mL/min, P = 0.023). CONCLUSION: RITA provides significantly higher free flow than LITA but similar blood flow to the LAD. Full skeletonization with intraluminal papaverine injection maximizes both free flow and ITA-LAD flow.

Impact of Steroid on Macrophage Migration Inhibitory Factor During and After Cardiopulmonary Bypass.

Macrophage migration inhibitory factor (MIF) is a proinflammatory cytokine released in response to glucocorticoids, which counter-regulates the effects of glucocorticoids. This study was performed to determine the impact of steroids on the expression of MIF and other pro- and anti-inflammatory cytokines during and after cardiopulmonary bypass (CPB). Twenty adult patients (10 men, 64 ± 8 years old) who underwent elective cardiac surgery by CPB were given either 2000 mg (group-H, n = 10) or 500 mg of methylprednisolone (group-L, n = 10) during CPB. The serum concentrations of MIF, interleukin (IL)-1ß, IL-8, IL-10, and tumor necrosis factor-alpha (TNF-α) were measured at eight time points until 36 hours after skin closure. The early postoperative course was uneventful for all patients. There were no significant differences in duration of operation, CPB, or aortic cross-clamping (AXC) between the two groups. MIF and IL-10 levels peaked just after the conclusion of CPB and decreased gradually thereafter. IL-1ß, IL-8, and TNF-α were undetectable throughout the study period. There were no significant differences in MIF or IL-10 levels between the two groups. Peak levels of MIF in all patients were significantly correlated with the duration of CPB and AXC, whereas no such correlation was observed for IL-10. MIF or IL-10 levels were significantly elevated during and after CPB, but there were no differences between the two doses of steroid administration. Both steroid doses sufficiently suppressed proinflammatory cytokines. MIF better reflected the invasiveness of the operation than IL-10.

Patency of separate tube grafts for intercostal artery reconstruction: Size and length matter.

OBJECTIVES: Low patency is a major concern when using separate tube grafts for intercostal artery reconstruction. Our goal was to elucidate the optimal size and length of grafts from their patency and the computational fluid dynamics (CFD). METHODS: The patency, size and length of separate tube grafts were evaluated in 41 patients. Simulation of CFD was performed in a model derived from a patient with a patent 12-mm graft that was 15 mm long, with 2 simulation models with a smaller (8-mm) or longer (30-mm) graft. RESULTS: A total of 49 grafts were used for intercostal artery reconstruction. There was 1 in-hospital death and 2 spinal cord injuries. The patency rate, which could be evaluated in 46 grafts, was 63% (29/46). It was 71% (24/34) in thoracoabdominal aortic replacement and 42% (5/12) in descending aortic replacement. Among 14 patients in whom all grafts were occluded, no patients developed spinal cord injury. All grafts longer than 25 mm were occluded (n = 5). Eight- and 10-mm grafts showed better patency than 12-mm grafts in thoracoabdominal aortic replacement (P = 0.008) when grafts were shorter than 25 mm. Simulation of CFD revealed vortical flow within the 12-mm graft, which did not reach the intercostal orifice, whereas helical flow was maintained throughout the cardiac cycle within the 8-mm graft. CONCLUSIONS: Eight- and 10-mm grafts seemed better than 12-mm grafts, and grafts should be kept shorter than 25 mm. Simulation of CFD may shed light on the issue of the optimal intercostal artery reconstruction technique.

Lipid biomarkers that reflect postoperative recurrence risk in lung cancer patients who smoke: a case-control study.

BACKGROUND: The risk of postoperative recurrence is higher in lung cancer patients who smoke than non-smokers. However, objective evaluation of the postoperative recurrence risk is difficult using conventional pathological prognostic factors because of their lack of reproducibility. Consequently, novel objective biomarkers that reflect postoperative risk in lung cancer patients who smoke must be identified. Because cigarette smoking and oncogenesis alter lipid metabolism in lung tissue, we hypothesized that the lipid profiles in lung cancer tissues are influenced by cigarette smoking and can reflect the postoperative recurrence risk in smoking lung cancer patients. This study aimed to identify lipid biomarkers that reflect the smoking status and the postoperative recurrence risk. METHODS: Primary tumor tissues of lung adenocarcinoma (ADC) (n = 26) and squamous cell carcinoma (SQCC) (n = 18) obtained from surgery were assigned to subgroups according to the patient's smoking status. The ADC cohort was divided into never smoker and smoker groups, while the SQCC cohort was divided into moderate smoker and heavy smoker groups. Extracted lipids from the tumor tissues were subjected to liquid chromatography-tandem mass spectrometry analysis. Lipids that were influenced by smoking status and reflected postoperative recurrence and pathological prognostic factors were screened. RESULTS: Two and 12 lipid peaks in the ADC and SQCC cohorts showed a significant positive correlation with the Brinkman index, respectively. Among them, in the ADC cohort, a higher lipid level consisted of three phosphatidylcholine (PC) isomers, PC (14:0_18:2), PC (16:1_16:1), and PC (16:0_16:2), was associated with a shorter recurrence free period (RFP) and a greater likelihoods of progressed T-factor (≥ pT2) and pleural invasion. In the SQCC cohort, a lower m/z 736.5276 level was associated with shorter RFP and greater likelihood of recurrence. CONCLUSIONS: From our data, we propose three PC isomers, PC (14:0_18:2), PC (16:1_16:1), and PC (16:0_16:2), and a lipid peak of m/z 736.5276 as novel candidate biomarkers for postoperative recurrence risk in lung ADC and SQCC patients who are smokers.

Management of noncerebral malperfusion complicating acute type A dissection.

Vital organ malperfusion in acute type A aortic dissection is associated with worse outcomes, especially when multiple organ systems are involved, and when coronary or mesenteric malperfusion is present. To achieve the two goals of central aortic repair and adequate and timely reperfusion, mechanism and organ-specific strategy in the methods and sequence of repair should be considered. For dynamic aortic malperfusion, reperfusion can be quickly achieved by femoral artery perfusion, and the fenestrated frozen elephant trunk operation, in which the proximal end of device is secured to zone 1 or 2 and distal 1 or 2 supra-aortic vessels are preserved by fenestration of the fabric, seems optimal as a method of central aortic repair. For coronary malperfusion, percutaneous coronary intervention before central aortic repair may have a role. However, it should be kept in mind that the door-to-unloading time is also important to reduce the area of myocardial infarction, and retrograde cardioplegia is not distributed to most of the right ventricle, which can be critical when right coronary malperfusion is present. Static mesenteric malperfusion should be addressed first, and second-look laparotomy should not be hesitated after central aortic repair. The use of a hybrid operating room may be an optimal solution to achieve both goals.

Surgical Approaches to Single-Stage Extended Aortic Repair from the Ascending to the Distal Descending Aorta.

Single-stage extended replacement from the ascending to the distal descending aorta or beyond is a formidable operation that should be preserved for those who have no other option or those who are physically fit, and should be performed in the experienced centers. Hybrid operations combining open surgical repair with thoracic endovascular aortic repair through a median sternotomy incision are preferable because these operations are less invasive than the extended open aortic repair and the risk of spinal cord ischemia is lower compared with the frozen elephant trunk operation. However, these operations are associated with the inherent demerits of endovascular aneurysm exclusion. When the underlying aortic pathology necessitates extended open aortic repair in a single stage, approaches such as the anterolateral partial sternotomy, straight incision with rib cross, and extended thoracotomy with sternal transection may be useful to provide sufficient exposure for both aortic reconstruction and organ protection, with less surgical stress to the patients.

18-Fluorodeoxyglucose positron emission tomography in the diagnosis of prosthetic aortic graft infection: the difference between open and endovascular repair.

OBJECTIVES: 18-Fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) has been reported as useful for diagnosing aortic graft infection. However, 18F-FDG uptake may depend upon various factors including open versus endovascular repair and time from surgery. We aimed to elucidate the factors influencing its uptake and the diagnostic value of 18F-FDG PET/CT after open and endovascular repair. METHODS: Hospital database of PET/CT (N = 14 490) and our departmental database were cross-checked to identify those who underwent 18F-FDG PET/CT after aortic repair. Patient's data were retrieved from the chart. Images were reviewed by 2 nuclear medicine specialists in consensus, and the presence of increased 18F-FDG uptake was recorded. The maximum standardized uptake value (SUV max) was measured. RESULTS: Among the 1112 patients who underwent aortic repair between 2011 and 2022, 71 patients were identified. Eighteen patients underwent 18F-FDG PET/CT for suspected graft infection and the remaining 53 patients for other purposes (malignancy, etc.). Fourteen patients were treated as aortic graft infection. They had significantly higher SUV max than those without graft infection [mean 8.64 (standard deviation 2.78) vs 3.40 (standard deviation 0.84); P < 0.01]. In the non-infected grafts, SUV max was higher early after open surgical repair, while it remained low after endovascular repair. CONCLUSIONS: After endovascular aortic repair, a constant cut-off value of 'SUV max = 4.5' seems appropriate for diagnosing graft infection, since it remains low and stable from the early postoperative period. After open surgical repair, it seems acceptable to have 'stepwise cut-off value' depending on the time from surgery.

Retention index of FDG-PET/CT SUVmax of the primary tumor in non-small cell lung cancer as a predictor of lymph node metastasis: a retrospective study.

BACKGROUND: Accurate staging of non-small cell lung cancer is key in treatment planning and prediction of prognosis. We investigated the correlation between the maximum standardized uptake value (SUVmax) retention index (RI) of the primary tumor and lymph node metastasis in non-small cell lung carcinoma. We also evaluated the tendencies according to the histological types. METHODS: We retrospectively evaluated 218 non-small cell lung cancer (NSCLC) tumors from 217 patients who underwent preoperative fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) followed by lung surgery and lymph node resection between July 2015 and August 2020. All primary tumors were calculated as the SUVmax at 50 min (SUVmaxearly [SUVmaxe]) and 120 min (SUVmaxdelayed [SUVmaxd]), and RI. The clinicopathological factors of interest were compared based on lymph node metastasis status and NSCLC histopathological subtype. RESULTS: The median SUVmaxe and SUVmaxd of the primary tumors were 3.3 and 4.2, respectively, and the median RI was 0.25. The RI was significantly higher in the pN(+) (n = 44) group (0.30) compared to the pN0 (n = 174) group (0.24) (p = 0.01). In patients with adenocarcinoma (n = 145), the RI was also significantly higher in the pN(+) (n = 29) group (0.29) compared to the pN0 (n = 116) group (0.16) (p < 0.01). A high RI of the primary tumor was an independent risk factor for lymph node metastasis, particularly in patients with adenocarcinoma (odds ratio: 12.30, p < 0.05). CONCLUSIONS: The RI of primary NSCLC tumors can help predict lymph node metastases, particularly in patients with adenocarcinoma.