P224 Valvuloplasty treatment and three-dimensional analysis for isolated cleft of the anterior mitral valve leaflet: a case report

Introduction: Isolated cleft of the anterior mitral valve leaflet is a very rare congenital disease and a cause of mitral regurgitation

not associated with atrioventricular septal defect. In this case, we report our experience in valvuloplasty treatment for mitral regurgitation with this rare aetiology.

Case description

23-year-old Russian women. Although cardiac murmur was pointed out in her childhood and she was diagnosed as mitral regurgitation, she refused treatment. After getting married with a Japanese man and moving to Japan, her symptoms had worsened and she visited our hospital for treatment. Preoperative transthoracic echocardiography (TTE) had indicated the regurgitation from the central part of the mitral valve. Preoperative transoesophageal echocardiography (TOE) had pointed out the isolated cleft of the anterior mitral valve.

Surgical mitral valvuloplasty was scheduled, and the TOE after anaesthetic induction showed the isolated cleft of the anterior mitral valve the same as in the preoperative period and pointed out the posterior leaflet billowing. The operative finding was also similar to TOE: the largely bisected central anterior mitral valve and billowing, P2 billowing, shortening of P1 and P3, P2-3 cleft. There were no chords at the anterior cleft. The valvuloplasty was performed including five-time pump runs in total: 1) Continuous suture for the anterior cleft and ring annuloplasty were performed, and the regurgitation was seemed to be almost controlled at the water-leak test and the ink test; 2) Artificial chordae and leaflet plications were added to residual regurgitation from the posterior region; 3)The residual regurgitation was controlled to Mild but it became a lateral jet toward the ring; 4)Mild remnant flow was pointed out: the regurgitation seemed to be from the posterior cleft, where immediately below the ring suture; 5) Pericardium patch was added and the remnant flow was almost eliminated. The pump was weaned and the operation was finished without any problems.

Discussion

The cause of difficulty in this valvuloplasty was thought to be caused by the difficulty in evaluating the mitral valve morphology. It was evident that the anterior leaflet of the mitral valve was largely bisected. However, it was difficult to evaluate the coaptation line and area due to the absence of chordal cords in the anterior cleft and the billowing or shortening of the posterior leaflet. Although preoperative three-dimensional analysis helped evaluating the isolated cleft and the regurgitation was almost controlled in the evaluation in the operation field, nevertheless, a residual regurgitation occurred and indicated in the TOE after re-beating.

Conclusion

It is important and necessary to use fine evaluation of coaptation is needed in valvuloplasty for isolated cleft of the anterior mitral valve leaflet; not only apply three-dimensional analysis but also apply two-dimensional echocardiogram.

Abstract P224 Figure.

P662 Synchrony between the right and left heart systems is recovered after TAVI in patients with severe aortic stenosis

Funding Acknowledgements

Young Investigator Grant of Japanese Society of Cardiovascular Anesthesia

Background / Introduction

Evidences have shown that cardiac function decline and systolic phase change are caused by massive afterload of the stenosed aortic valve in patients with severe aortic valve stenosis. As a result of the reduction of the left ventricular afterload by valve replacement, the cardiac function recovers. However, it has not been clarified yet how the changes in cardiac function affect the relationship between the right and left heart systems, as well as the systole phase.

TAPSE and MAPSE are known as indices of simple cardiac function evaluation by measuring the movement distance of the atrioventricular annulus. We obtained these indices (i.e. TAPSE, MAPSE) within the same heartbeat using speckle tracking analysis of the atrioventricular annulus and evaluated the changes in cardiac function and phase between the right and left heart systems.

Purpose

To reveal the relationship of cardiac function and time phase between the right and left heart systems by evaluating the maximum movement distance and time of the atrioventricular annulus within the same heartbeat and the same view in patients with severe aortic valve stenosis before and after TAVI.

Methods

A prospective cohort study was conducted. We recruited and analyzed 44 patients with severe aortic valve stenosis who received TAVI treatment, able to record baseline before treatment and follow-up 6 months and 12 months after treatment at our hospital from March 2017 to May 2019. Patients were excluded if more than 2 degree of atrioventricular valve regurgitation or incomplete data. The apical four-chamber view was used for speckle tracking analysis with the origin of the apical extension and region of interest (ROI) of the mitral annulus and tricuspid annulus. For each patient before treatment, at 6 months and 12 months after treatment, the maximum contraction distance (DM), maximum contraction time (TM) of the mitral valve annulus, maximum contraction distance (DT) and maximum contraction time (TT) of the tricuspid annulus were measured. Maximum contraction distance ratio (DM/ DT) and maximum contraction time ratio (TM/ TT) were calculated. For statistical analysis, t-test and ANOVA were used, and a significance threshold of p <0.05 was applied.

Results

TM/ TT decreased at 12 months after TAVI, and DM/ DT increased significantly at 6 months and 12 months after TAVI when compared to baseline before treatment.

Conclusions

In patients with severe aortic valve stenosis, the correction of cardiac function difference between the right and left heart systems occurs from 6 months after TAVI. Moreover, the correction of contraction phase difference between the right and left heart systems at 12 months after TAVI. Thus, the synchrony between the right and left heart system is recovered 12 months after TAVI.

Abstract P662 Figure.

Correction to: An efficient system for homology-dependent targeted gene integration in medaka (Oryzias latipes)

[This corrects the article DOI: 10.1186/s40851-017-0071-x.].

Curative Criteria After Endoscopic Resection for Superficial Esophageal Squamous Cell Carcinomas

BACKGROUND

According to the Japanese Esophageal Society (JES) guidelines, risk factors for lymph node (LN) metastasis in the muscularis mucosa (MM)/submucosa to a depth of up to 200 μm (SM1) in cases of esophageal squamous cell carcinomas (ESCCs) include the presence of lymphatic invasion (ly), venous invasion (v), infiltration pattern (INF)c, and SM1. The long-term prognoses of these patients are unclear, and there are very few reports on the validation of the curative criteria for MM/SM1 ESCCs.

AIMS

To examine the long-term prognoses of these patients and the risk factors for LN metastasis of MM/SM1 ESCCs after endoscopic resection (ER).

METHODS

This study included patients with MM/SM1 ESCCs who underwent ER at Hiroshima University Hospital from December 1990 to November 2016. We evaluated the clinicopathological characteristics of 98 patients and overall survival, disease-specific survival, recurrence-free survival, and recurrence rates in the e-curative and non-e-curative groups.

RESULTS

The mean observation period was 75 months. There was no significant difference in disease-specific survival rate between the e-curative and non-e-curative groups (100 vs. 98%). There was no significant difference in disease-specific survival rates between the groups (100 vs. 98%). In contrast, the LN recurrence-free survival rate in patients with INFa, ly(-), and v(-) was significantly higher than that in patients with INFb/c, ly(+), or v(+) (100 and 87%, P < 0.05).

CONCLUSION

Contrary to the JES guidelines, our findings suggest that new criteria (MM/SM1, INFa, negative vertical margin (VM0), ly[-], and v[-]) may be associated with curative ER without additional treatment.

The presence of multiple NS5A RASs is associated with the outcome of sofosbuvir and ledipasvir therapy in NS5A inhibitor-naïve patients with chronic HCV genotype 1b infection in a real-world cohort

It is unclear whether multiple nonstructural (NS) 5A resistance-associated substitutions (RASs) correlate with the outcome of sofosbuvir (SOF) and ledipasvir (LDV) therapy. We investigated the effects of multiple NS5A RASs in NS5A inhibitor-naïve patients with chronic hepatitis C virus genotype 1b infection treated with SOF/LDV. In 313 patients treated with SOF/LDV, we assessed the effects of multiple NS5A RASs on the sustained virological response (SVR). RASs at L28, R30, L31, Q54, P58, Q62, A92, and Y93 in the NS5A region were examined by direct sequencing. The prevalence of RASs was as follows: 2.6% at L28, 8.7% at R30, 6.1% at L31, 48.7% at Q54, 9.9% at P58, 9.9% at Q62, 5.1% at A92, 13.8% at Y93, and 19.2% at L31 or Y93. A total of 133 patients had no RASs. SVR was achieved in 98.7% of the patients. SVR rates significantly differed between patients with and without the L31 or Y93 RAS (93.0% [53/57] vs 100% [250/250], P = .0011). In addition, among patients with the L31 or Y93 RAS, 29.8%, 45.6% and 24.6% had one, two and three or more NS5A RASs, respectively. The SVR rate was significantly lower in patients with the L31 or Y93 RAS with more than three NS5A RASs compared to those with fewer than three NS5A RASs (71.4% [10/14] vs 100% [43/43], P = .0025). Although the prevalence of multiple NS5A RASs at baseline was low in NS5A inhibitor-naïve patients, the presence of multiple NS5A RASs was associated with the effectiveness of SOF/LDV therapy.

Possibility of chest wall dose reduction using volumetric-modulated arc therapy (VMAT) in radiation-induced rib fracture cases: comparison with stereotactic body radiation therapy (SBRT)

The present study compares dosimetric parameters between volumetric-modulated arc therapy (VMAT) and 3D conformal radiation therapy (3D-CRT) in lung tumors adjacent to the chest wall treated with stereotactic body radiation therapy (SBRT). The study focused on the radiation dose to the chest wall of 16 patients who had developed radiation-induced rib fractures (RIRF) after SBRT using 3D-CRT. The targets in all patients were partially overlapping with the fractured ribs, and the median overlapping rib-PTV distance was 0.4 cm. Stereotactic body radiation therapy was re-planned for all patients. The prescribed dose was 48 Gy in four fractions to cover at least 95% of the planning target volume (PTV). Evaluated dosimetric factors included D98% and the conformation number (CN) of the PTV, the D2cm3, V40 and V30 of the fractured ribs, the V30 of the chest wall, and the Dmean, V20 and V5 of the lung. A comparison of 3D-CRT with the VMAT plan for PTV revealed that CN was significantly improved in the VMAT plan, whereas D98% did not significantly differ between the two plans. Regarding organs at risk (OARs), the D2cm3, V40 and V30 of fractured ribs, the V30 of the chest wall, and the Dmean, V20 and V5 of the lung, were significantly decreased in the VMAT plan. We concluded that the dose to OARs such as ribs and chest wall could be reduced with improved target conformity using VMAT instead of 3D-CRT for SBRT to treat peripheral lung tumors.

Changes in maxillofacial morphology due to improvement of nasal obstruction in rats

OBJECTIVES

To investigate the effect of release of experimentally introduced nasal obstruction on maxillofacial morphology and percutaneous arterial oxygen saturation (SpO₂ ) in rats.

MATERIALS AND METHODS

Six-week-old male Wistar rats (n = 36) were divided into a control group (n = 6) and a nasal obstruction group (n = 30). In the nasal obstruction group, the right nostril was occluded with silicon, which was subsequently removed after a given experimental period (days 7, 21, 35, 49 and 63). These animals were then divided into groups D7, D21, D35, D49 and D63 (each n = 6), according to the day at which the obstruction was released. The SpO₂ was measured in rats with nasal obstruction at five experimental points. The maxillofacial morphology in rats on the first day and 63 days after the start of the experiment was evaluated by microcomputed tomography.

RESULTS

The SpO₂ was still lower at 2 weeks after the improvement of the nasal obstruction in the D49 group than in the control group. In addition, the height of the nasal maxillary complex of the D35, D49 and D63 groups was significantly decreased compared with the control group.

CONCLUSIONS

The results of this study suggest that long-term unilateral nasal obstruction in growing rats may affect the growth of the nasomaxillary complex and reduce the SpO₂ permanently. Therefore, early improvement of nasal obstruction in rats during the growth period may improve the SpO₂ and cranial development and promote normal growth and development.

Medaka-microinjection with an Upright Microscope

We described a simple method for microinjecting DNA/RNA/Protein solutions into medaka eggs under an upright microscope. Medaka is an excellent vertebrate model for reverse genetics, because of its daily spawning, short generation time, and egg transparency. These features enable us to efficiently perform functional genomic analyses of transgenic or genome edited fish. This protocol contains the initial steps necessary to create various types of genetically modified fish.

Experimental technique for antiproton-nucleus annihilation cross section measurements at low energy

The interaction of very low energy antiprotons (ps) and antineutrons (ns) with nuclei is interesting for its influence on both fundamental cosmology and nuclear physics. Measuring the annihilation cross section of antimatter on matter can help in solving the universe matter-antimatter puzzle and could give relevant hints in the definition of strong interaction model parameters as well. The ASACUSA collaboration recently measured the antiproton-carbon annihilation cross section at 5.3 MeV of kinetic energy of the incoming antiproton. The experimental apparatus consisted in a vacuum chamber containing thin foils (~0.7-1 μm) of carbon crossed by a bunched beam of antiprotons from the CERN Antiproton Decelerator (AD). The fraction of antiprotons annihilating on the target nucleons gives origin to charged pions which can be detected and counted by segmented scintillators placed outside the chamber. This work describes the experimental details of the apparatus and the technique to perform the cross section measurements.

Antiproton-nucleus annihilation cross section at low energy

The antinucleon-nuclei annihilation cross sections at low energies were systematically measured at CERN in the 80’s and 90’s with the LEAR facility and later with the Antiproton Decelerator. Unfortunately only few data exist for very low energy antiprotons (p<500 MeV/c) on medium and heavy nuclei. A deeper knowledge is required by fundamental physics and can have consequence also in cosmology and medical physics. In order to fill the gap, the ASACUSA Collaboration has very recently measured the annihilation cross section of 100 MeV/c antiprotons on carbon. In the present work the experimental result is presented together with a comparison both with the antineutron data on the same target at the same energies and with the other existing antiproton data at higher energies.

Crystallization and vitrification of electrons in a glass-forming charge liquid

Charge ordering (CO) is a phenomenon in which electrons in solids crystallize into a periodic pattern of charge-rich and charge-poor sites owing to strong electron correlations. This usually results in long-range order. In geometrically frustrated systems, however, a glassy electronic state without long-range CO has been observed. We found that a charge-ordered organic material with an isosceles triangular lattice shows charge dynamics associated with crystallization and vitrification of electrons, which can be understood in the context of an energy landscape arising from the degeneracy of various CO patterns. The dynamics suggest that the same nucleation and growth processes that characterize conventional glass-forming liquids guide the crystallization of electrons. These similarities may provide insight into our understanding of the liquid-glass transition.

An efficient system for homology-dependent targeted gene integration in medaka (Oryzias latipes)

BACKGROUND

The CRISPR/Cas system is a powerful genome editing tool that enables targeted genome modifications in various organisms. In medaka (Oryzias latipes), targeted mutagenesis with small insertions and deletions using this system have become a robust technique and are now widely used. However, to date there have been only a small number of reports on targeted gene integration using this system. We thus sought in the present study to identify factors that enhance the efficiency of targeted gene integration events in medaka.

RESULTS

We show that longer homology arms (ca. 500 bp) and linearization of circular donor plasmids by cleavage with bait sequences enhances the efficiency of targeted integration of plasmids in embryos. A new bait sequence, BaitD, which we designed and selected by in silico screening, achieved the highest efficiency of the targeted gene integration in vivo. Using this system, donor plasmids integrated precisely at target sites and were efficiently transmitted to progeny. We also report that the genotype of F₂ siblings, obtained by mating of individuals harboring two different colors of fluorescent protein genes (e.g. GFP and RFP) in the same locus, can be easily and rapidly determined non-invasively by visual observations alone.

CONCLUSION

We report that the efficiency of targeted gene integration can be enhanced by using donor vectors with longer homologous arms and linearization using a highly active bait system in medaka. These findings may contribute to the establishment of more efficient systems for targeted gene integration in medaka and other fish species.

Identification of Heschl's gyrus on phase difference enhanced imaging

Background The white matter in the Heschl's gyrus (HG-WM) may appear differently to the other gyri on phase difference enhanced imaging (PADRE), which can enhance the myelin density. Purpose To evaluate the signal intensity (SI) of HG-WM using the PADRE technique and to compare the images with susceptibility-weighted imaging (SWI)-like images. Material and Methods The participants included 19 normal controls (38 HGs; mean age, 60.1 years; age range, 28-80 years). Coronal PADRE and SWI-like images were acquired using a 3T magnetic resonance (MR) system. The SI of the HG-WM was classified into three grades based on a comparison with the SI of the superior temporal gyrus: Grade 1, isointense; Grade 2, slightly hypointense, and Grade 3, markedly hypointense. Results In the assessment of the SI of the HG-WM, the HG-WM appeared hypointense in all 38 sites of the 19 participants; the hypointensity corresponded to Grade 2 in 13 (34%) images and Grade 3 in 25 (66%) images. On the other hand, the HG-WM was classified as Grade 1 (isointense) in all of the SWI-like images. Conclusion The HG-WM appears hypointense on PADRE, which probably reflects the higher myelin content. PADRE may be useful for identifying the HG through the assessment of the SI of the HG-WM.

[L-shaped Partial Upper Sternotomy Approach for Aortic Valve Replacement]

Transcatheter aortic valve implantation is a recent innovation in the treatment of severe aortic stenosis. On the other hand, several reports suggested that minimally invasive aortic valve replacement (MICS-AVR) is likely to be associated with reduced postoperative discomfort and faster recovery. Of note, an upper partial sternotomy for isolated aortic valve replacement( L-shaped MICS-AVR) has been accepted as the most common approach to the MICS-AVR. Since October 2013, we have preformed L-shaped MICS-AVR at our hospital. In L-shaped MICS-AVR group(16 patients, 74.4±8.7 years),there was no operative mortality and any other complication including reexploration for postoperative bleeding, wound infection, peri-valvular leakage, pulmonary complication like re-intubation or minitracheostomy. To demonstrate the benefits of this approach, over-octogenarian subgroup( n=7)was analyzed and compared with the isolated AVR using a conventional sternotomy (C-AVR, n=10)in the same period. A trend was seen toward better postoperative course in the L-shaped MICS-AVR group than in the C-AVR group;however, this difference was not statistically significant. The mean duration of cardiopulmonary bypass(120±29 min vs 93±24 min, p=0.005)and cross clamp time(151±36 min vs 124±32 min, p=0.038)were significantly longer than C-AVR. We believe that more clinical experience is required to clarify the benefits of this approach and we must more consider the preoperative images for the attainment of the excellent exposure. Moreover, the concomitant use of this new device and L-shaped MICS-AVR may enable a big improvement in the future.

Randomized clinical trial of duct-to-mucosa pancreaticogastrostomy versus handsewn closure after distal pancreatectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a major cause of morbidity after distal pancreatectomy. The aim of this study was to investigate whether duct-to-mucosa pancreaticogastrostomy of the pancreatic stump decreased clinical POPF formation compared with handsewn closure after distal pancreatectomy.

METHODS

This multicentre RCT was performed between April 2012 and June 2014. Patients undergoing distal pancreatectomy were assigned randomly to either duct-to-mucosa pancreaticogastrostomy or handsewn closure. The primary endpoint was the incidence of clinical POPF. Secondary endpoints were rates of other complications and length of hospital stay.

RESULTS

Some 80 patients were randomized, and 73 patients were evaluated in an intention-to-treat analysis: 36 in the pancreaticogastrostomy group and 37 in the handsewn closure group. The duration of operation was significantly longer in the pancreaticogastrostomy group than in the handsewn closure group (mean 268 versus 197 min respectively; P < 0·001). The incidence of clinical POPF did not differ between groups (7 of 36 versus 7 of 37; odds ratio (OR) 1·03, 95 per cent c.i. 0·32 to 3·10; P = 1·000). The rate of intra-abdominal fluid collection was significantly lower in the pancreaticogastrostomy group (6 of 36 versus 21 of 37; OR 0·15, 0·05 to 0·45; P < 0·001). There were no statistically significant differences in the rates of other complications or length of hospital stay.

CONCLUSION

Duct-to-mucosa pancreaticogastrostomy did not reduce the incidence of clinical POPF compared with handsewn closure of the pancreatic stump after distal pancreatectomy. Registration number UMIN000007426 (http://www.umin.ac.jp).

Core I97L mutation in conjunction with P79Q is associated with persistent low HBV DNA and HBs antigen clearance in patients with chronic hepatitis B

OBJECTIVES

When considering treatment for chronic hepatitis B (CHB), it is important to discriminate between patients with persistent low HBV DNA and patients with active hepatitis, who may proceed to cirrhosis. In this study, we sought to identify mutations in patients expected to have persistent low HBV DNA and ultimately exhibit clearance of hepatitis B surface antigen (HBsAg).

METHODS

Serum samples were obtained from 33 CHB genotype C patients, divided based on HBV DNA and alanine aminotransferase (ALT) levels following observation for >2 years: Group A (n=10), transient HBV DNA ≥5.0 log copies/mL and ALT ≥120 IU/L; Group B (n=11), persistent HBV DNA <5.0 and ALT <60; and Group C (n=12), persistent HBV DNA <4.0 and ALT <30. Full-length HBV sequences were compared among groups. Subsequently, 82 patients with CHB were evaluated for the I97L mutation and the additional mutation P79Q. We compared cumulative incidences of persistent low HBV DNA and HBsAg clearance in patients with or without I97L and P79Q by the Kaplan-Meier method.

RESULTS

Incidence of Core mutation I97L differed significantly among groups: A, 30% (3/10); B, 36.4% (4/11); C, 83.3% (10/12) (p = 0.021). Cumulative incidences of persistent low HBV DNA and HBsAg clearance were significantly higher in patients with I97L than in those with wild-type I97 (p = 0.003 and p = 0.016, respectively), and even higher in those with P79Q.

CONCLUSIONS

In patients with CHB, measurement of I97L and additional mutation P79Q would be useful for predicting persistent low HBV DNA, normal ALT, and HBsAg clearance.

Role of definitive chemoradiotherapy using docetaxel and 5-fluorouracil in patients with unresectable locally advanced esophageal squamous cell carcinoma: a phase II study

Definitive chemoradiotherapy (CRT) with docetaxel (DOC) and 5-fluorouracil (5-FU) is a unique regimen for esophageal cancer. In this prospective phase II study, antitumor effect and safety of CRT using DOC and 5-FU for inoperable locally advanced esophageal cancer were evaluated. DOC 7.5 mg/m² was infused on days 1, 8, 22, and 29. 5-FU 250 mg/m² /day was infused continuously on days 1-5, 8-12, 15-19, 22-26, 29-33, 36-40, and 43-45. Radiotherapy was given to 66 Gy in 33 fractions. Eleven patients with thoracic and five with cervical esophageal cancer were eligible. All patients had esophageal squamous cell carcinoma (ESCC). The response rate was 94%, with complete response in five patients (31%) and partial response in 10 (63%). Hematologic toxicity was mild; only one patient (6%) had Grade 1 leukopenia. Nonhematologic Grade 3 or higher adverse events were esophagitis (31%), anorexia (6%), and esophago-bronchial fistula (6%). No treatment-related deaths occurred. The median time to progression was 20 months and overall 3-year and 5-year survival were 44% and 31%, respectively. Definitive CRT using DOC and 5-FU could be performed safely, and it demonstrated a favorable antitumor effect for ESCC. This regimen might be indicated in patients in whom it is desirable to avoid myelosuppression and progression of renal impairment.

Successful surgical treatment of traumatic sternal fracture with extensive mediastinal abscess and concomitant mitral valve endocarditis: a case report

Background

A traumatic sternal fracture with extensive mediastinal abscess and concomitant native valve endocarditis is an extremely rare but catastrophic situation.

Case presentation

For 2 weeks, the co-infected patient was treated with aggressive debridement for the mediastinitis, change of vacuum-assisted closure therapy dressings, vegetectomy and valve repair through lower partial sternotomy, and delayed primary wound closure.

Conclusions

To the best of our knowledge, this successful staged strategy has not been previously reported. We believe that our quick decision about repeated surgical interventions and preservation of the manubrium led to a favorable result.