Aortic Stenosis in a Patient With Sjogren's Syndrome

Sjogren's syndrome (SS) is an autoimmune disease characterized by dryness of the mouth and the eyes. Systemic involvement in SS is well known, however, obvious cardiac manifestations, particularly significant valve disorders, are extremely rare and only three cases of significant valve disease associated with SS that required surgical intervention have been previously described. We report a case of aortic stenosis (AS) associated with SS in an elderly patient. The diagnosis of primary SS had been made based on clinical features, positive ocular signs, and positive serologic findings. Echocardiography showed severe calcification, elevated mean pressure gradient (57 mmHg), and a small orifice area (0.45 cm(2)) of the aortic valve. At surgery, severe calcification of the aortic cusps and the annulus was the mechanism of AS, and the aortic valve was replaced with a bioprosthetic valve. Valve pathology showed nodular calcification and hyaline degeneration, but lymphocyte infiltration was not evident. The etiologic relation of SS to the valve lesions is not clear pathologically in this case, however, chronic inflammation related to immunologic reactions in SS could have some effect on exacerbation for degeneration of the valve tissue.

Isolated Tricuspid Valve Endocarditis Caused by Infection of an Implanted Central Venous Access Port Device

A 70-year-old man was referred to our hospital for an intermittent high fever attributed to subcutaneous pocket infection of an implanted central venous access port device caused by methicillin-resistant staphylococcus aureus and subsequent bloodstream infection. Echocardiography revealed a large vegetation on the posterior tricuspid leaflet, annular dilatation and moderate-to-severe tricuspid regurgitation. Valve surgery was performed for persistent infection despite 8 weeks of antibiotics therapy. At operation, vegetations and torn chordae tendineae were found on the posterior tricuspid leaflet. After total resection of the posterior tricuspid leaflet, bicuspidalization valvuloplasty with prosthetic ring annuloplasty was achieved without relapse of the infection or residual regurgitation.

MMP13 can be a useful differentiating marker between squamous cell carcinoma and benign hyperkeratotic lesions in recessive dystrophic epidermolysis bullosa

Recessive dystrophic epidermolysis bullosa (RDEB) is a severe hereditary mechanobullous disease resulting from mutations in the COL7A1 gene, coding for type VII collagen. Patients with RDEB tend to develop squamous cell carcinomas (SCCs) at sites of chronic ulceration or scarring on the whole body. Distinguishing SCC from benign hyperkeratotic lesions is often difficult, not only clinically but also histologically in patients with RDEB. We investigated several matrix metallopeptidase (MMP) subtypes by comparing the DNA amplification microarray findings between evident SCCs and benign hyperkeratotic lesions in the same patient with RDEB. We report that MMP13 was found to be strongly positive in SCCs but negative in benign hyperkeratotic lesions. We found that there is an evident difference in the transitional area between SCCs and benign hyperkeratotic lesions. We propose that MMP13 may be a useful differentiating marker between SCC and benign hyperkeratotic lesions in RDEB.

A surgical case of papillary fibroelastoma originating from the left atrial ridge

Papillary fibroelastomas are benign cardiac tumors with high embolic tendency, and usually originate from the cardiac valve. We report the case of a 49-year-old man who experienced sudden right hemiplegia and aphasia. Transesophageal echocardiography indicated a swinging tumor originating from the left atrial ridge between the orifice of the left atrial appendage and the anterolateral mitral annulus. Urgent tumor resection was performed to prevent further embolization. The histological findings of resected tumor were consistent with those of papillary fibroelastoma. To the best of our knowledge, all cases of papillary fibroelastomas that originate from the left atrial ridge are associated with cerebral vascular accidents. Therefore, prompt surgical resection is strongly recommended to prevent embolic events for those patients. <Learning objective: Papillary fibroelastomas are benign cardiac tumors and typically originate from valvular surfaces with high potential of embolization. To avoid embolic events, urgent excision of the tumor tends to be performed. All previously reported cases with papillary fibroelastoma at the left atrial ridge accompanied embolic events, therefore surgical excision should be under consideration in all such patients, regardless of the symptom, size, or configuration.>.

Lessons from 28 cases of reconstruction by lenticular island pedicle flap at a single institution

BACKGROUND

Lenticular island pedicle flap (LIPF) has been reported to be one of the most useful techniques for reconstructing middle cheek skin defects. LIPF may have been used all over the world on a daily basis; however, no reports have examined a large number of LIPF cases at a single institution.

MATERIALS AND METHODS

A total of 28 cases of reconstruction by LIPF at the Hokkaido University Hospital from 2005 to 2013 were analysed. We examined the tumour type, location, area of defect and presence/absence of antithrombotic treatment and complications, including transient circulatory impairment, damage to facial nerves and eyelid ectropion.

RESULTS

We found that nine patients had transiently impaired circulation. This complication was statistically more frequent in the patients without antithrombotic treatment than in the patients with antithrombotic treatment (0/8 vs. 10/20, P = 0.0292; Fisher's exact test).

CONCLUSION

We revelled that LIPF have been safely performed even under antithrombotic treatment, so, when patients are taking antithrombotic agents, we should choose LIPF rather than conventional flap including cheek flap, island pedicle flap and so on.

Ebstein's anomaly in adult patients over 50 years of age

Ebstein's anomaly (EA) is a rare congenital heart disease of the tricuspid valve, and less than 5% of patients with EA survive beyond the age of 50. We report two unoperated cases of EA in adult patients aged over 50 years. Two patients, a 70-year-old Japanese woman and a 59-year-old Chinese woman, were referred to us for tachyarrhythmias. Transthoracic echocardiography demonstrated apical displacement (>8 mm/m(2) body surface area) of the septal leaflet of the tricuspid valve from the atrioventricular ring with tricuspid regurgitation in both patients. The former suddenly expired 20 months later after suffering from repetitive supraventricular tachyarrhythmias and/or heart failure, and the latter is alive with minimal signs of heart failure 12 months after the diagnosis of EA. Although the natural history of EA is extremely variable, these two patients are exceptional in that they tolerated EA well for over 50 years without any surgical intervention.

A novel splice site mutation in NCSTN underlies a Japanese family with hidradenitis suppurativa

BACKGROUND

 Hidradenitis suppurativa (HS) is a chronic follicular occlusive disease with characteristic recurrent draining sinuses, skin abscesses and disfiguring scars, mainly involving the axilla, groin, perianal and perineal regions. While most HS cases are nonfamilial, familial cases showing autosomal dominant inheritance have been reported. Recently, loss-of-function mutations in the genes encoding γ-secretase have been identified as a cause of familial HS in the Chinese and British populations.

OBJECTIVES

 To identify mutations in the genes encoding γ-secretase in Japanese patients with familial and nonfamilial HS.

METHODS

 Two affected and three unaffected individuals from a Japanese family with familial HS and nine patients with nonfamilial HS were recruited. We conducted mutation analysis of the γ-secretase genes in Japanese patients with familial and nonfamilial HS.

RESULTS

  A novel splice site mutation in the nicastrin gene NCSTN, one of the six key component genes encoding γ-secretase, was identified in the patients with familial HS. Neither unaffected individuals in the family nor 100 ethnically matched control alleles carry this mutation. None of the nine patients with nonfamilial HS carry nonsense, frameshift or splice site mutations in this gene.

CONCLUSIONS

  A novel splice site mutation, c.582+1delG, in NCSTN was identified in the familial patients with HS. We also reveal for the first time that a γ-secretase gene mutation is not linked to the development of nonfamilial HS. These results would further pave the way to a better understanding of the contribution of γ-secretase and other genes to the pathogenesis of HS and to the development of a new therapeutic strategy for HS.

Preoperative visualization of the artery of Adamkiewicz by dual-phase CT angiography in patients with aortic aneurysm

To improve our ability to visualize the Adamkiewicz artery (AKA), we developed a modified intravenous CT angiography technique, which we refer to as right atrial CT (RA-CT) angiography. In this study, AKA detection rate and visualization of the arterial continuity from the aorta to the anterior spinal cord artery (ASA) was evaluated using RA-CT angiography.We performed RA-CT angiography in 110 patients with abdominal, thoracic descending, or thoracoabdominal aortic aneurysms. In RA-CT angiography, contrast medium with a high iodine concentration (370 mg/dl) was injected twice into the right atrium at a high injection rate (8.0 ml/sec), and two CT scans, starting at 20 sec after the first injection and at 35 sec after the second injection, respectively, were performed. All CT images were obtained using an 8- or 16-detector CT scanner at a slice thickness of 0.625 mm. The AKA was defined as the largest radiculomedullary artery with a characteristic hairpin turn, and with continuity from the aorta to the ASA.The AKA with hairpin turn was detected in all patients (100%), and continuity from the aorta to the ASA was confirmed in 99 of the 110 patients (90.0%). The AKA arose between Th8 and L1 in 86 of these patients (86.8%), and originated from the left side in 71 patients (71.7%).RA-CT angiography may be useful for visualizing the AKA and the arterial continuity from the aorta to the ASA in patients with aortic aneurysm, although the use of more advanced CT machines will provide safe and easy identification of the AKA and arterial continuity with a small amount of contrast medium and a single scan.

MUC5AC expression correlates with invasiveness and progression of extramammary Paget's disease

BACKGROUND

Patients with in situ extramammary Paget's disease (EMPD) tend to have a good prognosis, although dermal invasion and metastasis are associated with significantly increased morbidity and mortality. Previous studies have addressed mechanisms underlying the EMPD pathogenesis; however, no molecular markers that reflect invasiveness or progression have been established.

OBJECTIVE

This study aims to identify a reliable marker for predicting the risk of invasion and metastasis in EMPD.

METHODS

We performed an initial microarray screening for in situ, invasive or metastatic lymph node lesions of EMPD. We analysed 44 specimens from 38 primary EMPD cases by immunohistochemical staining.

RESULTS

We found that expressions of MUC5AC directly correlate with invasion and prognosis. Labelling rates of tumour cells were scored by staining intensity on a four-tiered scale (- to 3+) to investigate the correlation between the expression score of these molecular markers and the type of EMPD lesion. All the specimens scored positive (3+) for MUC1 and negative (-) for MUC6. MUC5AC expression was detected in 19 of 44 (43.2%) specimens. Invasive lesions and metastatic lymph nodes tended to express MUC5AC significantly higher than in situ lesions (P < 0.01). MUC2 was positive in 10 specimens (22.7%). There was no significant difference between the degree of MUC2 expression and invasiveness.

CONCLUSION

The degree of MUC5AC expression may correlate with the invasiveness and progression of EMPD, and may be a useful marker for identifying high-risk EMPD cases.

Structural valve deterioration in a starr-edwards mitral caged-disk valve prosthesis

BACKGROUND

The durability of the Starr-Edwards (SE) mitral caged-disk valve, model 6520, is not clearly known, and structural valve deterioration in the SE disk valve is very rare.

METHODS AND RESULTS

Replacement of the SE mitral disk valve was performed in 7 patients 23-40 years after implantation. Macroscopic examination of the removed disk valves showed no structural abnormalities in 3 patients, in whom the disk valves were removed at <26 years after implantation. Localized disk wear was found at the sites where the disk abutted the struts of the cage, in disk valves excised >36 years after implantation in 4 patients. Disk fracture, a longitudinal split in the disk along its circumference at the site of incorporation of the titanium ring, was detected in the valves removed 36 and 40 years after implantation, respectively, and many cracks were also observed on the outflow aspect of the disk removed 40 years after implantation.

CONCLUSIONS

Disk fracture and localized disk wear were found in the SE mitral disk valves implanted >36 years previously. The present results suggest that SE mitral caged-disk valves implanted >20 years previously should be carefully followed up, and that those implanted >30 years previously should be electively replaced with modern prosthetic valves