Association Between the Redox State of Human Serum Albumin and Exercise Capacity in Patients With Cardiac Disease

The redox state of human serum albumin (HSA) is reported to be an oxidative stress biomarker; however, its clinical use in cardiac disease has not yet been examined. This study aimed to investigate the relation between the redox state of HSA and exercise capacity, which is a robust prognostic factor, in patients with cardiovascular disease. This cross-sectional study included outpatients with cardiac disease. Exercise capacity was assessed by peak oxygen consumption (peakVO₂) measured using symptom-limited cardiopulmonary exercise testing. The high-performance liquid chromatography postcolumn bromocresol green method was used to part HSA into human nonmercaptalbumin (oxidized form) and human mercaptalbumin (HMA, reduced form). The fraction of human mercaptalbumin found in HSA (f[HMA]) was calculated as an indicator of the redox state of HSA. The association between peakVO₂ and f(HMA) was examined using the Spearman correlation coefficient and multivariate linear regression analysis. A total of 70 patients were included (median age 76 years; 44 men; median peakVO₂ 15.5 ml/kg/min). The f(HMA) was positively correlated with peakVO₂ (r = 0.38, p <0.01). Even after controlling for potential confounders, this association remained in the multivariate linear regression analysis (standardized beta = 0.24, p <0.05). We found a positive association between f(HMA) and peakVO₂, independent of potential confounders in patients with cardiac disease, suggesting that f(HMA) may be a novel biomarker related to exercise capacity in cardiac disease. Longitudinal studies are required to further examine the prognostic capability of f(HMA), the responsiveness to clinical intervention, and the association between f(HMA) and cardiac disease.

Novel Brain Protection Method for Zone 0 Endovascular Aortic Repair with Selective Cerebral Perfusion

Objective: Zone 0 thoracic endovascular aortic repair (TEVAR) is associated with a high incidence of cerebral infarction mostly due to the embolic shower of a plaque from the aortic arch when the stent graft brushes against the aortic wall. Thus, it is important to develop a method for protecting the brain from such embolism. We report the outcomes of Zone 0 TEVAR with a novel brain protection method using selective cerebral perfusion under extracorporeal membrane oxygenation (ECMO).

Materials and Methods: Two T-shaped grafts with ringed expanded polytetrafluoroethylene (ePTFE) were created using an 8-mm-ringed ePTFE anastomosed end-to-side with a 7-mm-ringed ePTFE. Carotid–carotid bypass and axillo-axillary bypass were established using these grafts. ECMO was connected to the grafts and the femoral vein. Bilateral carotid and axillary arteries were blocked, and cerebral perfusion was selectively maintained using ECMO. Total endovascular Zone 0 TEVAR was performed. The patency of brachiocephalic artery was maintained using the chimney or in situ fenestration technique.

Results: Since August 2016, seven patients with aortic arch aneurysms underwent the procedure. The mortality rate was 0%. No neurological complications developed.

Conclusion: This brain protection method using selective cerebral perfusion under ECMO is a safe method for Zone 0 TEVAR.

Successful Two-Stage Treatment for Coarctation of the Aorta-postductal Type and Aortic Regurgitation with Thoracic Endovascular Aortic Repair and Aortic Valve Replacement

We herein report a case of a 20-year-old man with aortic regurgitation (AR), coarctation of the aorta (CoA), and patent ductus arteriosus (PDA). The preoperative ankle–brachial pressure index was 0.56 in bilateral extremities. Enhanced computed tomography revealed CoA-postductal type. We decided to perform a two-stage surgery: thoracic endovascular aortic repair (TEVAR) for CoA and PDA and then open surgery for AR. TEVAR was successfully performed with deployment of the stent graft at a 31-mm diameter subsequent to balloon dilation. At 8 days after TEVAR, the patient underwent aortic valve replacement via median sternotomy and was discharged without a complication.

Prospective validation of 0-hour/1-hour algorithm using high-sensitivity cardiac troponin I in Japanese patients presenting to emergency department

Background

The diagnostic performance of 0-hour/1-hour algorithm using high-sensitivity cardiac troponin I (hsTnI) for non-ST-segment elevation myocardial infarction (NSTEMI) has not been evaluated in an Asian population.

Purpose

We aimed to prospectively validate the 0-hour/1-hour algorithm using hsTnI in a Japanese population.

Method

We enrolled 754 Japanese patients (mean age of 70 years, 395 men) presenting to our emergency department with symptoms suggestive of NSTEMI. The hsTnI concentration was measured using the Siemens ADVIA Centaur hsTnI assay at presentation and after 1 hour. Patients were divided into three groups according to the algorithm: hsTnI below 3 ng/L (only applicable if chest pain onset &gt;3 hours) or below 6 ng/L and delta 1 hour below 3 ng/L were the “rule-out” group; hsTnI at least 120 ng/L or delta 1 hour at least 12 ng/L were in the “rule-in” group; the remaining patients were classified as the “observe” group. Based on the Fourth Universal Definition of Myocardial Infarction, the final diagnosis was adjudicated by 2 independent cardiologists using all available information, including coronary angiography, coronary computed tomography, and follow-up data. Safety of rule-out was quantified by the negative predictive value (NPV) for NSTEMI, accuracy of rule-in by the positive predictive value (PPV), and overall efficacy by the proportion of patients triaged towards rule-out or rule-in within 1 hour.

Results

Prevalence of NSTEMI was 6.5%. The safety of rule-out (NPV 100%), accuracy of rule-in (PPV 26%), and overall efficacy (54%) were shown in Figure.

Conclusion

The 0-hour/1-hour algorithm using hsTnI is very safe and effective in triaging Japanese patients with suspected NSTEMI.

Funding Acknowledgement

Type of funding source: None

Clinical Application of an Original Flexible MK Stent-Graft for Nonruptured Thoracic Aortic Aneurysms: Early Experience

Objective

To obtain early MK stent-grafting results for nonruptured thoracic aortic aneurysms and thoracoabdominal aortic aneurysms.

Methods

The authors analyzed 47 patients who underwent treatment using MK stent-grafting. All patients (40 men and 7 women; mean age, 70.8 years) underwent elective procedures. Straight, curved, or tapered MK stents were constructed from a nitinol wire and covered with seamless, cylindrical woven polyester fabric grafts. The mean stent-graft diameter was 24 to 48 mm. In cases where the aneurysm had a short proximal neck (under 15 mm), supraaortic arch artery bypass surgery was planned to lengthen the neck.

Results

Simple stent-grafting without bypass was performed in 26 patients, whereas stent-grafting with supraaortic arch artery bypass was performed in 21 patients. An 18 or 20 F sheath was used as the delivery system in 46 patients (96%). In all 47 patients, the stent-grafts were successfully deployed. Two patients died while in hospital, and another 2 patients suffered a stroke. No other perioperative complications were observed. Postoperative computed tomography after 3 months showed complete thrombus formation in 42 patients (93.3%; 42/45 patients).

Conclusions

Forty-seven patients with thoracic aortic aneurysm were treated with our original flexible MK stent-graft system. Using a small sheath system, straight or curved M-K stent-grafts could be deployed to adequately fit to the aorta as planned. Furthermore, simultaneous bypass surgery widened the application of stent-grafting. However, careful long-term observation is necessary, and further studies are needed to assess such stent-grafting with bypass surgery.

Nonresectional Simplified Folding Technique in Robotic Mitral Valve Plasty: Comparison with Leaflet Resection Technique

OBJECTIVE

The mitral valve plasty (MVP) technique for degenerative disease is typically leaflet resection and suturing. However, this technique is time consuming and unreproducible. To overcome this disadvantage, we developed a nonresectional folding technique, which is fast and reproducible. In this report, we examine our new folding technique in robotic MVP.

METHODS

The new folding technique was performed in 10 patients (age 56 ± 15 years), and the conventional resection and suturing (RS) technique was performed in 22 patients (age 53 ± 8 years). In our new folding technique, we used two sutures to fold the prolapsed leaflet to the left ventricle side. The first folding suture line is a land mark, and the second line adjusts the height of the posterior leaflet to the anterior leaflet so that sufficient coaptation depth can be obtained.

RESULTS

MVP was successful in all patients. In the folding technique group, the operation time, cardiopulmonary bypass time, and cross clamp time was faster than the conventional RS technique group (188 ± 31, 97 ± 32, and 55 ± 3 min, versus 242 ± 51, 137 ± 25, and 70 ± 15 min; P < .05). Hospital stays were significantly shorter in the folding technique group (13 ± 2 days versus 17 ± 7 days; P < .05). All patients were discharged without complications. The post-echocardiography revealed no mitral valve regurgitation in any patient.

CONCLUSION

The new folding technique facilitated efficient MVP for posterior leaflet prolapse in mitral valve regurgitation, without the need for the resection of the leaflet.

Robotic mitral valve plasty for mitral regurgitation after blunt chest trauma in Barlow's disease

We successfully treated a case of mitral regurgitation due to chest trauma in Barlow's disease. A 71-year-old man was admitted with severe mitral regurgitation after blunt compression of the chest by a heavy object 5 months earlier. Preoperative examination revealed wide chordae tendineae rupture and myxomatous changes to the bileaflets. Neo-chordae reconstruction of the anterior mitral leaflet using loop technique, triangular resection of the posterior mitral leaflet, and ring annuloplasty was performed via surgical robot. Robotic mitral valve plasty for severe mitral regurgitation due to chest trauma in Barlow's disease was achieved safely with good clinical and excellent cosmetic results.

Surgical Repair for the Treatment of Pulmonary Vein Stenosis After Radiofrequency Ablation

Radiofrequency ablation procedures for atrial fibrillation are occasionally associated with pulmonary vein stenosis (PVS). A common treatment for PVS is catheter intervention; however, because of the high restenosis rate, it is not suitable for young patients. The case presented herein is of a young male patient with severe bilateral PVS who underwent successful surgical pulmonary vein repair by sutureless technique. The stenotic lesions of the pulmonary veins were dissected and were covered using autologous pericardium. An enhanced computed tomographic scan revealed that all the pulmonary veins were widely patent after 6 months from the operation.

[Emergency Thoracic Endovascular Aortic Repair of Ruptured Kommerell's Diverticulum with an Acute Aortic Dissection]

This case report describes emergency thoracic endovascular aortic repair (TEVAR) of a ruptured Kommerell's diverticulum associated with a type B acute aortic dissection in a patient with a right aortic arch. A 64-year-old male was admitted with symptoms of sudden paraplegia and shock. The computed tomography imaging showed right aortic arch anomaly, with mirror image branching of the major arteries. The aorta was dissected from the origin of the right subclavian artery to the terminal aorta, with a thrombosed false lumen. Rupture was found in a 6.3 cm aneurysm located in the distal arch, which was diagnosed as Kommerell's diverticulum. We performed emergency TEVAR, and the aneurysm was successfully excluded using deployment of a Gore Tag stent-graft. At 3 months' follow-up, the patient was doing well and showed shrinkage of the aneurysm was confirmed. TEVAR is considered to be a suitable procedure for an emergency aortic catastrophe even in patients with aortic anomaly.

Totally endoscopic robotic resection of left atrial myxoma with persistent left superior vena cava

A 68-year old man with a cardiac tumour was admitted for robotic tumour resection using the da Vinci S Surgical System. While undergoing preoperative examination, he was found to have a persistent left superior vena cava. After general anaesthesia and single-lung ventilation, cardiopulmonary bypass was established, with venous drainage through bilateral internal jugular and right femoral veins and arterial return through the right femoral artery. Robotic tumour resection was performed by four ports in the right chest. There were no difficulties during the operation, and successful tumour resection was achieved with satisfactory margins. He was discharged without complications. Persistent left superior vena cava is very rare, but if diagnosed preoperatively and an appropriate operative plan is made, robotic cardiac surgery can be performed safely. With robotic surgery, cardiac tumour resection can be feasibly performed, with cosmetic benefits.

A novel one-shot circular stapler closure for atrial septal defect in a beating-heart porcine model

PURPOSE

In surgical atrial septal defect (ASD) closure, there are no techniques or devices that can close the ASD accurately in a short time under a beating heart. We have developed a simple and automatic ASD closure technique using a circular stapler. This study assessed the feasibility and efficacy of a new circular stapler closure for ASD.

DESCRIPTION

Under a continuous beating heart, hand-sewn patch plasty ASD closure was performed in 6 pigs (group A) and circular stapler ASD closure was performed in 6 pigs (group B). The time to close the ASD and the effectiveness of the closure were compared.

EVALUATION

Closure was significantly faster in group B (10.5 ± 1.0 seconds) than in group A (664 ± 10 seconds; p < 0.05). There was no leakage at the closure site, and sufficient tolerance was confirmed.

CONCLUSIONS

A circular stapler can be used to treat ASD faster than hand-sewn patch plasty, with sufficient pressure tolerance in a beating heart porcine model.

Robotic resection of dual accessory mitral valve tissue in an adult patient

The presence of isolated accessory mitral valve tissue (AMVT) is extremely rare in adults. We successfully performed robot-assisted resection of dual AMVT that was attached to the papillary muscle and anterior mitral leaflet. Echocardiography was invaluable for identifying the most suitable approach. The short-axis view on echocardiography revealed the precise location where the AMVT was attached. The robotic operation enabled fine visualization; we clearly observed the AMVT and removed its entire extra structure. The patient recovered well and was discharged 3 days after the operation. To the best of our knowledge, this is the first report of successful robotic AMVT resection.

Kidney fibrosis is independent of the amount of ascorbic acid in mice with unilateral ureteral obstruction

In response to sustained damage to a kidney, fibrosis that can be characterized as the deposition of a collagenous matrix occurs and consequently causes chronic kidney failure. Because most animals used in experiments synthesize ascorbic acid (AsA) from glucose, the roles of AsA in fibrotic kidney diseases are largely unknown. Unilateral ureteric obstruction (UUO) mimics the complex pathophysiology of chronic obstructive nephropathy and is an ideal model for the investigation of the roles of AsA in kidney failure. We examined the impact of a deficiency of Akr1a, a gene that encodes aldehyde reductase and is responsible for the production of AsA, on fibrotic damage caused by UUO in mice. Oxidatively modified DNA was elevated in wild-type and Akr1a-deficient kidneys as a result of UUO to a similar extent, and was only slightly suppressed by the administration of AsA. Even though Akrla-deficient mice could produce only about 10% of the AsA produced by wild-type mice, no difference was observed in collagen I synthesis under pathological conditions. The data implied either a low demand for AsA or the presence of another electron donor for collagen I production in the mouse kidney. Next, we attempted to elucidate the potential causes for oxidative damage in kidney cells during the fibrotic change. We found decreases in mitochondrial proteins, particularly in electron transport complexes, at the initial stage of the kidney fibrosis. The data imply that a dysfunction of the mitochondria leads to an elevation of ROS, which results in kidney fibrosis by stimulating cellular transformation to myofibroblasts.

A Simple, Natural and Effective Framework of Nonlinear Systems Control and its Application to Aerial Robots

This paper presents a simple, natural and effective framework of nonlinear systems control and its application to aerial robots. First, we present a framework of Takagi-Sugeno fuzzy model-based control and also discuss its feature. Next, a number of design problems for the control framework are formulated as numerically feasibility problems of representing in terms of linear matrix inequalities. Finally, we provide two applications of the control framework to aerial robots. The control results of aerial robots show the utility of the control framework.

En bloc vascular resection for the treatment of borderline resectable pancreatic head carcinoma

Borderline resectable (BR) pancreatic head carcinoma (PhC) is an advanced disease, presenting with infiltration of major vessels. Major vascular resection (VR), particularly arterial resection, to achieve microscopic no residual tumor (R0) is a controversial approach, due to the potential complications. In this study, we aimed to clarify the benefit of en bloc R0 resection with VR for PhC by retrospectively evaluating 78 PhC patients who underwent pancreatoduodenectomy at our institute. The patients were divided into 4 groups as follows: R, resectable (n=20); BR-V, BR involving the superior mesenteric vein or portal vein (PV) (n=28); BR-SMA, BR involving the superior mesenteric artery (n=21); and BR-HA, BR involving the hepatic artery (n=9). In total, 65 patients underwent VR, with 63, 21 and 9 patients undergoing PV, SMA and HA resection, respectively. The R0 rates were as follows: R group, 85%; BR-V, 82%; BR-SMA, 71%; and BR-HA, 33%. The median survival time and 5-year survival rate for R0 resection were 31 months and 25% in the R group, 22 months and 28% in the BR-V group, 17 months and 27% in the BR-SMA group and 10 months and 0% in the BR-HA group, respectively. The prognosis was comparable among the BR-V, BR-SMA and R groups, but was significantly poorer in the BR-HA group. In total, 5 patients (6.4%) died perioperatively (4 from postoperative hemorrhage and 1 from suffocation due to failure of expectoration, without pneumonia or asthma). Of the 4 patients who succumbed to hemorrhage, 3 had undergone arterial resection. Therefore, en bloc resection with major VR for R0 may be suitable for BR-V and BR-SMA PhC patients.

A novel coronary active perfusion system using a conventional intra-aortic balloon pump for off-pump coronary artery bypass grafting

OBJECTIVE

It is important for coronary active perfusion systems to avoid myocardial ischemia during off-pump coronary artery bypass grafting. We have developed a new concept for a perfusion system to pump blood based on changes in helium gas volume. This system uses a conventional intra-aortic balloon pump to activate the perfusion pump. Our study used basic and animal experiments to investigate the most suitable system for coronary perfusion using this new concept.

METHODS

A conventional intra-aortic balloon pump was used to supply power. A device for perfusion was developed with a balloon placed inside a stiff syringe barrel. The device was connected to the helium gas line of the intra-aortic balloon pump. Changes in flow with changes in augmentation level were noted when volumes outside and within the balloon were changed. Six pigs with occlusion of the left anterior descending artery were used for system validation, with monitoring to identify changes in hemodynamics and cardiac enzyme levels.

RESULTS

In the basic experiment, an 80-mL outside volume and 3.0-mL inner volume resulted in the greatest percentage change in flow rate with respect to changes in augmentation. In the animal experiment, the new coronary active perfusion system prevented myocardial ischemia during coronary occlusion.

CONCLUSIONS

We clarified the most suitable method for our new coronary active perfusion system. Using this system, safe anastomosis was consistently performed in animal experiments. Clinically, off-pump coronary artery bypass may potentially be performed more safely and easily using this new system.

Endovascular repair of a traumatic thoracic aortic injury resulting in late aortic dilatation

We present an unusual complication following endovascular repair of traumatic thoracic aortic injury using a homemade stent-graft. Although an initial technical success was apparently obtained, the aorta showed remarkable dilatation without shortening or migration of the stent skeleton in late follow-up period. The possible cause of the dilatation was considered to be the expansion and gathering of the crimped, loosely attached, graft fabric in addition to the incomplete exclusion due to the insufficient landing zone and the limited radial force. Thus, the specific feature of stent-graft, considered to provide an advantage to treatment, has adversely affected the native aorta.

Monitoring brain oxygen saturation during awake off-pump coronary artery bypass

OBJECTIVE

To evaluate the changes in cerebral blood flow during awake off-pump coronary artery bypass grafting and compare with the changes during off-pump coronary artery bypass grafting under general anesthesia, using continuous monitoring of regional cerebral oxygen saturation.

METHODS

The study population comprised 3 groups of patients who had undergone off-pump coronary artery bypass grafting with thoracic epidural anesthesia, general anesthesia, or a combination of the two. Regional brain oxygen saturation, determined with a near-infrared oxygen monitor, and mean arterial pressure during surgery were calculated and compared among the 3 groups.

RESULTS

Patients who had undergone awake off-pump coronary artery bypass grafting with thoracic epidural anesthesia had a significantly higher cerebrovascular impairment ratio, and the EuroSCORE was high. No significant differences were observed among the 3 groups in terms of the relationship between mean arterial pressure during surgery and regional brain oxygen saturation. It is suggested that there were no differences in cerebral blood flow and mean arterial pressure changes among the 3 groups.

CONCLUSIONS

Awake off-pump coronary artery bypass grafting is a safe surgical technique for patients with history of cerebral infarction or impaired cerebral blood flow. Awake off-pump coronary artery bypass grafting is a less invasive procedure that allows efficient management of intraoperative cerebral blood flow, and can be equally effective as a percutaneous coronary intervention.

Successful thoracic endovascular aortic repair of an aortoesophageal fistula

We report three cases of aortoesophageal fistula (AEF), in which the patients remained free from catastrophic bleeding after endovascular stent-grafting. The three patients, who were not candidates for surgical repair because of their poor general condition and prognosis, underwent endovascular stent-grafting following the administration of antibiotics and were successfully managed; hemostasis was maintained for several months until their death. Although we did not find any conclusive evidence to support this strategy, our experiences suggest that endovascular stent-grafting of AEF is useful for maintaining hemodynamic stability.

Development of a new aortoscope system for the use of endovascular intervention

"Balloon aortoscopy" is a technique for viewing inner wall of aorta and used in clinics. By this method, endoluminal aortic surface could be clearly monitored, however, during this period, the aortic blood flow is blocked off by the inflated balloon. To solve this clinical problem, we have been developing a prototype aortoscope system without blocking off aortic flow aiming for the use of an assistive technique for endovascular interventions such as stent-graft placement for aortic aneurysm and have been evaluating through in vitro and in vivo tests. The technique introduced for this purpose was the use of intermittent and instantaneous saline jet controlled by a high-speed electromagnetic valve synchronized to heart beat (diastolic phase). In the previous study, we designed an endoscope with two channels (one for saline discharge and the other for forceps insertion), and confirmed the validity of this method by in vitro and in vivo tests. Based on these findings, in this study, we have newly designed a conventional and low price endoscope system aiming for wide clinical use. From the results of in vitro tests using a mock circulation system, it was confirmed that the newly designed system was capable of visualizing a target installed on an inner surface of the mock system suggesting an availability of the system for an aortoscope without blocking off aortic flow.

Simultaneous surgical correction of pectus excavatum and cardiac disease in two adults

Thoracic reconstruction in patients with pectus excavatum with concomitant cardiac or aortic surgery poses a major clinical challenge. The report describes two cases of adult patients undergoing simultaneous surgical correction of cardiac disease and sternal deformity using one of two different techniques: a sterno-turnover method preserving the rectus muscle or a sternal elevation method with A-O plates.

Polynomial fuzzy observer designs: a sum-of-squares approach

This paper presents a sum-of-squares (SOS) approach to polynomial fuzzy observer designs for three classes of polynomial fuzzy systems. The proposed SOS-based framework provides a number of innovations and improvements over the existing linear matrix inequality (LMI)-based approaches to Takagi-Sugeno (T-S) fuzzy controller and observer designs. First, we briefly summarize previous results with respect to a polynomial fuzzy system that is a more general representation of the well-known T-S fuzzy system. Next, we propose polynomial fuzzy observers to estimate states in three classes of polynomial fuzzy systems and derive SOS conditions to design polynomial fuzzy controllers and observers. A remarkable feature of the SOS design conditions for the first two classes (Classes I and II) is that they realize the so-called separation principle, i.e., the polynomial fuzzy controller and observer for each class can be separately designed without lack of guaranteeing the stability of the overall control system in addition to converging state-estimation error (via the observer) to zero. Although, for the last class (Class III), the separation principle does not hold, we propose an algorithm to design polynomial fuzzy controller and observer satisfying the stability of the overall control system in addition to converging state-estimation error (via the observer) to zero. All the design conditions in the proposed approach can be represented in terms of SOS and are symbolically and numerically solved via the recently developed SOSTOOLS and a semidefinite-program solver, respectively. To illustrate the validity and applicability of the proposed approach, three design examples are provided. The examples demonstrate the advantages of the SOS-based approaches for the existing LMI approaches to T-S fuzzy observer designs.

Evaluation of a newly designed endoscope for observing inner wall of large arteries for the use of endovascular intervention

A prototype endoscope for observing inner wall of large arteries was specially designed and evaluated through in vitro and in vivo tests. The purpose of this endoscope is to visualize the inner wall of large arteries, e.g., an aorta, without blocking off the blood stream aiming for the use of an assistive technique for endovascular interventions such as stent-graft placement for aortic aneurysm. The technique newly introduced for this purpose was the use of intermittent high-pressure saline jet synchronized to heart beat (diastolic phase). In the previous studies using commercially available bronchoscopes, we confirmed the validity of the system utilizing this technique [1, 2]. Based on these findings, in this study, we have specially designed a new endoscope with two channels, one for saline discharge and the other for forceps, and evaluated its performance through in vitro and in vivo tests. From the results of in vitro tests using a mock circulation system, it was confirmed that the newly designed endoscope was capable of visualizing a target installed on an inner surface of the mock system. Also confirmed through in vivo tests using swine was that we could observe bifurcation in descending aorta, e.g., left renal artery, without stopping off the blood stream.

Pseudocoarctation of the aorta complicated by thoracic aortic aneurysm

Pseudocoarctation is a rare anomaly involving kinking or buckling of the aorta without a pressure gradient across the lesion, considered to be a benign entity warranting no specific intervention. An uncommon case of pseudocoarctation associated with aortic aneurysm formation in 21-year-old woman is described. Pathological findings suggested that the etiology was anomalous development of the aorta in association with pseudocoarctation; therefore, careful follow-up of patients affected by pseudocoarctation is mandatory.

Tepid hypothermic (32° C) circulatory arrest for total aortic arch replacement: a paradigm shift from profound hypothermic surgery

In total aortic arch replacement (TARCH) using hypothermic circulatory arrest (HCA) and selective cerebral perfusion (SCP), postoperative cerebral complications, including metabolic abnormalities, are by no means rare. Furthermore, there is a lack of international guidelines for the optimal perfusion temperature and flow for SCP. Starting in 2008, TARCH was performed using tepid HCA at 32 °C. In the present study, 27 patients (group C) who underwent TARCH with deep hypothermia at the lowest rectal temperatures of 20-25 °C were retrospectively reviewed and compared with 23 patients (group W) who underwent TARCH with 32 °C tepid hypothermia. Preoperative patient characteristics and intraoperative and postoperative parameters were compared. Preoperative patient characteristics did not differ significantly between the two groups. Circulatory arrest time, cardiopulmonary bypass time, operating time, amount of blood transfused and postoperative neurological complications were significantly reduced in group W compared with group C. Our procedure of TARCH using tepid hypothermia at 32 °C was safe, and it significantly reduced all parameters of extracorporeal circulation time. However, this study has several limitations. To indicate the safety and usefulness of tepid HCA for TARCH, a further multifaceted study should be performed with a greater number of patients.

Severe aortic insufficiency due to a huge leaflet perforation in Libman-Sacks syndrome: report of a case

A 40-year-old woman who was diagnosed to have systemic lupus erythematosus developed complications of cerebral infarction and alveolar hemorrhage. Close examination revealed severe aortic insufficiency, and she was diagnosed with Libman-Sacks syndrome. Due to progressive dilatation of the left ventricle and her easily fatigued state, surgery was performed. On pathological examination, holes of 4-mm and 5-mm diameter were detected in the left coronary and noncoronary cusps of the aortic valve, respectively. The morphology of the valve lesions showed a characteristic shape of such huge holes.

Neurological deficit after simultaneous open abdominal aortic surgery and thoracic aortic endovascular therapy

We examined a total of 12 cases; 8 cases were identified by searching the literature on Pubmed (excluding case reports published prior to 2000) and 4 cases were ones we personally encountered. We examined age, sex, history of smoking, and preoperative risk factors as preoperative factors, the access route and coverage of the descending aorta as perioperative factors, and complications and survival time as postoperative factors. Mean coverage of the thoracic aorta was 90.8 mm. In terms of perioperative deaths, 8.3% (1 patient) were due to coagulopathy. Perioperative complications occurred in 16.7% of cases (coagulopathy in 1 patient and paralysis in another). No patients experienced complications or underwent additional treatment during a mean follow-up of 22.9 months. This study suggested that simultaneous open abdominal aortic repair and thoracic aortic endovascular therapy is feasible and also involves few postoperative complications. Paraplegia and paralysis tended to occur less frequently than with two-stage surgery, but further study is needed to explain why this is true.

Inferior vena cava occluder for remote access perfusion in robotic cardiac surgery

Robotic cardiac surgery requires remote access perfusion. We have developed an inferior vena cava (IVC) occluder that can safely and conveniently drain blood from the IVC. This device has been clinically applied in one patient, as described herein. The framework for this device is made from a single superelastic nitinol wire, 0.30 mm in diameter. Diameter of the spreading site of the device is decided from computed tomographic images. A polyester fabric membrane (thickness 0.10 mm) is set at the tip of this framework. The occluder is deployed through an 18-F sheath. This device was used in a 64-year-old woman with lipoma in the right atrial wall near the IVC-right atrium interface. In this patient, it might not have been possible to completely reset the tumour by conventional IVC occlusion using a snare. The occluder was smoothly and safely deployed and retracted. During placement of the occluder, blood did not flow from the IVC into the right atrium. During extracorporeal circulation, vacuum drainage was performed with no air contamination. The tumour was resected by a three-arm da Vinci Surgical System. The IVC occluder needs to completely block the IVC and avoid obstructing the inflow region of the hepatic vein. This device obviates the need to place a snare on the IVC, and thus should directly improve the safety of robotic cardiac surgery and shorten the operating time.

Emergent thoracic endovascular aortic repair for acute type-B aortic dissection with malperfusion by matsui-kitamura stent graft

Acute type-B aortic dissection with malperfusion is a serious cardiovascular condition associated with high morbidity and mortality. Recent studies have investigated the efficacy of thoracic endovascular aortic repair (TEVAR) as treatment for acute aortic dissection. In this report, we present a case of acute type-B aortic dissection complicated with malperfusion, which was successfully treated with emergent TEVAR for entry closure by a Matsui-Kitamura stent graft (MKSG). MKSG is a flexible custom-made curved stent graft. The main advantages of MKSG for emergent TEVAR include flexibility, shape, and small profile when compressed.

Pseudoaneurysmal formation in abdominal aorta associated with Escherichia coli infection

Early and accurate diagnosis of infective aortic aneurysms (IAA) is critical for adequate treatment to optimize patient outcome. We report the case of an 84-year-old man who complained of severe back pain with high fever and was finally diagnosed as Escherichia coli-related IAA. Computed tomography showed a periaortic soft tissue density and irregular fringe adjacent to the non-dilated abdominal aorta suggesting the presence of pseudoaneurysm. In addition to intravenous antibiotic injection, an aneurysmectomy with extensive debridement and an in situ graft, were successfully performed. The case emphasizes the potential for rapid IAA change and the need for frequent radiologic follow-up.

T-graft technique under antegrade cerebral perfusion for aortic arch aneurysm

We have devised a T-graft technique for selected extensive aortic arch replacement under antegrade cerebral perfusion. Under hypothermic circulatory arrest using antegrade cerebral perfusion, one graft was island-anastomosed to the supraaortic arteries. The other graft was anastomosed to the descending aorta. Proximal and distal grafts were then end-to-side anastomosed in a T-shape. During rewarming, the ascending aorta and proximal graft were anastomosed. The surgical field was good in the 6 patients included in this report. No perioperative deaths or serious complications were encountered. This procedure was effective for patients with extensive aortic arch aneurysm and relatively intact orifices of the supraaortic arteries.