An 82-year-old man was admitted to our institution with a painful pulsating mass in the left groin. He had undergone bypass surgery with a bifurcated Cooley double velour knitted Dacron graft to treat aorto-iliac occlusive disease 21 years previously. Computed tomography demonstrated a 35-mm pseudoaneurysm near the distal anastomosis site of the graft. Opening the aneurysm revealed that the graft was disrupted along the guideline. We resected the aneurysm and interposed an expanded polytetrafluoroethylene (ePTFE) graft. Vascular surgeons should consider that grafts can fail in patients with long-term prosthetic grafts.

HomeCirculationVol. 124, No. 9Large Thrombus Originating From Left Atrial Diverticulum Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessBrief ReportPDF/EPUBLarge Thrombus Originating From Left Atrial DiverticulumA New Concern for Catheter Ablation of Atrial Fibrillation Takayuki Nagai, MD, Akira Fujii, MD, Kazuhisa Nishimura, MD, Katsuji Inoue, MD, Jun Suzuki, MD, Teruhito Kido, MD, Michitsugu Nakamura, MD, Yuji Matsumoto, MD, Hironori Izutani, MD, Teruhito Mochizuki, MD, Kanji Kawachi, MD, Jitsuo Higaki, MD and Akiyoshi Ogimoto, MD Takayuki NagaiTakayuki Nagai From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author , Akira FujiiAkira Fujii From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author , Kazuhisa NishimuraKazuhisa Nishimura From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author , Katsuji InoueKatsuji Inoue From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author , Jun SuzukiJun Suzuki From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author , Teruhito KidoTeruhito Kido From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author , Michitsugu NakamuraMichitsugu Nakamura From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author , Yuji MatsumotoYuji Matsumoto From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author , Hironori IzutaniHironori Izutani From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author , Teruhito MochizukiTeruhito Mochizuki From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author , Kanji KawachiKanji Kawachi From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author , Jitsuo HigakiJitsuo Higaki From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author and Akiyoshi OgimotoAkiyoshi Ogimoto From the Division of Cardiology, Department of Integrated Medicine and Informatics (T.N., A.F., K.N., K.I., J.S., J.H., A.O.), Department of Diagnostic and Therapeutic Radiology (T.K., T.M.), and Organ Regenerative Surgery (H.I., K.K.), Ehime University Graduate School of Medicine; and Division of Cardiology, Saijo Central Hospital, Saijo, Ehime, Japan (M.N., Y.M.). Search for more papers by this author Originally published30 Aug 2011https://doi.org/10.1161/CIRCULATIONAHA.110.000315Circulation. 2011;124:1086–1088A 45-year-old man was admitted to our hospital for evaluation of a left atrial (LA) mass. The patient had a history of dilated hypertrophic cardiomyopathy, atrial fibrillation (AF), diabetes mellitus, and sustained ventricular tachycardia that was treated by implantation of a cardioverter-defibrillator. He had developed AF 1 year earlier and was followed up at the outpatient clinic. He had been treated with warfarin at a dose that resulted in an international normalized ratio of 2.0 to 3.0. The LA mass was detected incidentally on routine transthoracic echocardiography. He was referred to our hospital because the size of the LA mass was unchanged after intensive anticoagulation with intravenous heparin infusion. The mobile LA mass along the interatrial septum was detected by transthoracic echocardiography in the apical 4-chamber view (Figure 1 and Movie I in the online-only Data Supplement). Transesophageal echocardiography showed a huge mobile mass (2.6×1.4 cm) originating from the roof of the LA (Figure 2A and Movie II in the online-only Data Supplement) with remarkable spontaneous echo contrast. No evidence of thrombus formation was found in the LA appendage (Figure 2B). The mass had a stalk that came from the diverticulum on the LA roof based on computed tomography (Figure 3 and Movie III in the online-only Data Supplement). Although the LA mass was presumed to be a thrombus, the differential diagnosis included a tumor, often detected as myxoma in the LA. He was treated by surgical removal of the LA mass combined with a maze procedure and closure of the LA appendage. A large thrombus with a short stalk originating from the diverticulum on the LA roof was clearly identified, and these structures, including the LA diverticulum, were removed at surgery. No obvious cauliflower-like formation was found on the LA wall, and the diagnosis of thrombus as well as diverticulum was confirmed by histology (Figure 4). The patient has remained in sinus rhythm for 3 months postoperatively, and transesophageal echocardiography revealed no LA thrombus, no evidence of residual LA diverticulum, and no sign of spontaneous echo contrast (Figure 5 and Movie IV in the online-only Data Supplement).Download figureDownload PowerPointFigure 1. Transthoracic echocardiography in the apical 4-chamber view showing a mobile left atrial (LA) mass (asterisk) along the interatrial septum (Movie I in the online-only Data Supplement). LV indicates left ventricle; RA, right atrium; and RV, right ventricle.Download figureDownload PowerPointFigure 2. A, Transesophageal echocardiography showing a large, mobile mass (asterisk) attached to the left atrial (LA) roof with marked spontaneous echo contrast (Movie II in the online-only Data Supplement). B, No evidence of thrombus formation was found in the left atrial appendage (LAA). LV indicates left ventricle; RA, right atrium.Download figureDownload PowerPointFigure 3. A and B, Computed tomography (256 slice) showing the diverticulum (white arrow) and mass (asterisk) within the left atrium (LA). No thrombus was detected in the left atrial appendage. C, Note that a stalk (black arrow) from the mass was attached to the LA roof diverticulum (Movie III in the online-only Data Supplement). RA indicates right atrium; RV, right ventricle.Download figureDownload PowerPointFigure 4. A, Histological findings of the left atrial mass showing evidence of thrombus formation. B, Histological findings of the left atrial wall attached to thrombus revealed that the tissue attached to the thrombus contained normal myocardium consistent with diverticulum.Download figureDownload PowerPointFigure 5. Transesophageal echocardiography 3 months after the surgical procedure revealed no left atrial (LA) thrombus, no evidence of residual LA diverticulum, and no sign of spontaneous echo contrast (Movie IV in the online-only Data Supplement). RA indicates right atrium.The progression of cardiac computed tomographic technology and the growing indication for catheter ablation of advanced AF have led to the identification of more patients with LA diverticulum originating from the anterior roof of the LA. The terms LA diverticulum and accessory LA appendage have both been used to describe structures protruding from the LA that have normal myocytes and are clearly different from a LA aneurysm. Accessory LA appendage is diagnosed if the structure is shaped like a cauliflower (ie, obvious neck at the ostium and the presence of pectinate muscles that resemble the true LA appendage).1,2 However, the discrimination between LA diverticulum and accessory LA appendage may often be difficult, and these 2 terms are used synonymously in the clinical setting. The incidence of LA diverticulum/accessory appendage was found to be 10% to 23%.2–4 This condition is thought to be associated with ectopic foci that initiate AF, incomplete ablation lines on the LA roof, and potential complications such as steam pop and cardiac tamponade during AF ablation. We report here the first case of a giant LA thrombus originating from LA diverticulum, without LA appendage thrombus formation, in a patient with AF. Our finding suggests that there may be a latent relationship between LA diverticulum and systemic embolic events during AF ablation.DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.110.000315/-/DC1.Correspondence to Takayuki Nagai, MD, Division of Cardiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan. E-mail [email protected]ehime-u.ac.jpReferences1. Lee WJ, Chen SJ, Lin JL, Huang YH, Wang TD. Accessory left atrial appendage: a neglected anomaly and potential cause of embolic stroke. Circulation. 2008; 117:1351–1352.LinkGoogle Scholar2. Abbara S, Mundo-Sagardia JA, Hoffmann U, Cury RC. Cardiac CT assessment of left atrial accessory appendages and diverticula. AJR Am J Roentgenol. 2009; 193:807–812.CrossrefMedlineGoogle Scholar3. Duerinckx AJ, Vanovermeire O. Accessory appendages of the left atrium as seen during 64-slice coronary CT angiography. Int J Cardiovasc Imaging. 2008; 24:215–221.CrossrefMedlineGoogle Scholar4. Killeen RP, Ryan R, MacErlane A, Martos R, Keane D, Dodd JD. Accessory left atrial diverticulae: contractile properties depicted with 64-slice cine-cardiac CT. Int J Cardiovasc Imaging. 2010; 26:241–248.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Celik E, Goertz L, Nelles C, Hammes J, Achenbach T, Kabbasch C, Persigehl T, Maintz D and Bunck A (2022) The Aortic Ductus Diverticulum—Innocent Bystander or Potential Source of Thromboembolic Stroke?, Journal of Computer Assisted Tomography, 10.1097/RCT.0000000000001287, 46:3, (392-396), Online publication date: 1-May-2022. Yoshihara S, Yaegashi T, Matsunaga M and Naito M (2022) Four Accessory Left Atrial Appendages, Internal Medicine, 10.2169/internalmedicine.8406-21, 61:10, (1621-1622), Online publication date: 15-May-2022. Schneider M, Morris D, Pieske‐Kraigher E, Walter‐Rittel T, Parwani A, Pieske B and Boldt L (2020) Left atrial diverticulum—An unexpected finding in routine transesophageal echocardiography, Echocardiography, 10.1111/echo.14949, 38:1, (147-148), Online publication date: 1-Jan-2021. Siddamsetti S, Kumar S and Gautam S (2021) Incidentally detected accessory left atrial appendage in a patient being planned for left atrial appendage closure, HeartRhythm Case Reports, 10.1016/j.hrcr.2021.05.007, 7:10, (709-711), Online publication date: 1-Oct-2021. Şeker M (2019) The characteristics of left atrial diverticula in normal sinüs rhythm patients, Surgical and Radiologic Anatomy, 10.1007/s00276-019-02382-w, 42:4, (377-384), Online publication date: 1-Apr-2020. Celik E, Pennig L, Laukamp K, Hammes J, Maintz D, Kabbasch C, Abdullayev N, Bunck A, Achenbach T, Caldeira L and Hickethier T (2020) Are left atrial diverticula and left-sided septal pouches relevant additional findings in cardiac CT? Correlation between left atrial outpouching structures and ischemic brain alterations, International Journal of Cardiology, 10.1016/j.ijcard.2020.05.038, 317, (216-220), Online publication date: 1-Oct-2020. Muthiah R (2017) Rheumatic Giant Left Atrium—An Overview, Case Reports in Clinical Medicine, 10.4236/crcm.2017.66017, 06:06, (164-195), . Hołda M, Koziej M, Wszołek K, Pawlik W, Krawczyk-Ożóg A, Sorysz D, Łoboda P, Kuźma K, Kuniewicz M, Lelakowski J, Dudek D and Klimek-Piotrowska W (2017) Left atrial accessory appendages, diverticula, and left-sided septal pouch in multi-slice computed tomography. Association with atrial fibrillation and cerebrovascular accidents, International Journal of Cardiology, 10.1016/j.ijcard.2017.06.042, 244, (163-168), Online publication date: 1-Oct-2017. Owais K, Montealegre-Gallegos M, Matyal R, Pal A and Mahmood F (2015) Left Atrial Appendage... and Another Appendage?, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2014.06.027, 29:1, (248-249), Online publication date: 1-Feb-2015. Vehian A, Choi B, Rekhi S, Young H, Dusaj R and Zeman R (2015) Clinical Significance of Left Atrial Anatomic Abnormalities Identified by Cardiac Computed Tomography, Advances in Computed Tomography, 10.4236/act.2015.41001, 04:01, (1-8), . Zimmerman S (2015) Left atrial diverticula Pearls and Pitfalls in Cardiovascular Imaging, 10.1017/CBO9781139152228.017, (54-56) Ding X, Zhu M, Wei C, Zhu H, Zhang X, Qu X, Li Y and Yuan J (2015) Double cardiac diverticula after pericardectomy, International Journal of Cardiology, 10.1016/j.ijcard.2015.08.029, 201, (449-453), Online publication date: 1-Dec-2015. Mandegar M, Moradi B, Roshanali F and Ojaghi Z (2014) Giant left atrial aneurysm, Journal of Cardiology Cases, 10.1016/j.jccase.2014.06.011, 10:4, (144-146), Online publication date: 1-Oct-2014. Genç B, Solak A, Kantarci M, Bayraktutan Ü, Ogul H, Yüceler Z, Öztürk A and Kizrak Y (2013) Anatomical features and clinical importance of left atrial diverticula, Clinical Anatomy, 10.1002/ca.22320, 27:5, (738-747), Online publication date: 1-Jul-2014. DE PONTI R, LUMIA D, MARAZZI R, MAMELI S, DONI L, DE VENUTO G, FUGAZZOLA C and SALERNO-URIARTE J (2013) Left Atrial Diverticula in Patients Undergoing Atrial Fibrillation Ablation: Morphologic Analysis and Clinical Impact, Journal of Cardiovascular Electrophysiology, 10.1111/jce.12213, 24:11, (1232-1239), Online publication date: 1-Nov-2013. Ko J, Kim Y, Hong Y, Lee H, Hur J, Choi B, Heo J, Kim Y and Minnerup J (2013) Lack of Association between Stroke and Left Atrial Out-Pouching Structures: Results of a Case-Control Study, PLoS ONE, 10.1371/journal.pone.0076617, 8:10, (e76617) Weerakkody Y (2015) Left atrial diverticulum Radiopaedia.org, 10.53347/rID-39885 August 30, 2011Vol 124, Issue 9 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.110.000315PMID: 21875923 Originally publishedAugust 30, 2011 PDF download Advertisement SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-Defibrillator

Giant traumatic coronary artery pseudoaneurysm is extremely rare, and very few cases of traumatic coronary artery aneurysm have been previously reported. We present a case of an asymptomatic, giant, traumatic right coronary artery pseudoaneurysm caused by blunt chest trauma and sternal fracture. The risk of rupture or peripheral embolization remains unclear, but we believe that pseudoaneurysm resection and coronary artery bypass grafting are adequate procedures for preventing rupture or ischemia.

Primary mediastinal liposarcomas are rare malignancies, comprising fewer than 1% of all mediastinal tumors. We herein report a radical resection of a massive liposarcoma arising from the anterior mediastinum. A 63-year-old male patient presented with a 4-week history of dyspnea that had worsened over the previous several days. The patient had also experienced hoarseness for 2 weeks. Chest X-ray and computed tomography revealed a huge tumor occupying the entire left thoracic cavity. Anesthesia was induced when the patient was in the left semilateral position. The patient was moved into the right lateral position after initially stabilizing anesthesia with separate lung ventilation. The fourth rib was initially resected for thoracotomy, but there was no clearance between the tumor and the adjacent mediastinal structures, and two more ribs were therefore removed. The tumor had not invaded the other structures such as the chest wall, lung, or mediastinum. To reduce the tumor blood flow, the left internal mammary artery was ligated before the tumor was resected en bloc. The tumor was diagnosed as a liposarcoma arising from the thymus. The patient remains alive with no evidence of disease recurrence at 22 months after the operation.

In this study, we perform a detailed analysis of the microglial and macrophage responses in a model of spinal cord ischemia and reperfusion (SCI/R) injury in Wistar rats. The rats underwent occlusion across the descending aorta for 13min, causing paraplegia or paresis of varying severity. They were divided into four groups based on neurological assessment: sham, mild paresis, moderate paresis, and severe (complete) paraplegia. To examine the origin of microglia and macrophages in the ischemic lesion, bone marrow from rats expressing green fluorescent protein (GFP) was transplanted into test subjects one month before performing SCI/R. Many GFP+/CD68+ microglia and macrophages were present 7d after SCI/R. Resident (GFP−/Iba1+/CD68−) microglia and bone marrow-derived macrophages (BMDMs; GFP+/Iba1+/CD68+) colocalized in the mild group 7d after SCI/R. In the moderate group, BMDMs outnumbered resident microglia. A greater accumulation of BMDMs expressing insulin-like growth factor-1 (IGF-1) was observed in lesions in the severe group, relative to the moderate group. BMDMs in the severe group strongly expressed tumor necrosis factor α, interleukin-1β, and inducible nitric oxide synthase, in addition to IGF-1. A robust accumulation of BMDMs occupying the entire ischemic gray matter was observed only in the severe group. These results demonstrate that the magnitude of the microglial and BMDM responses varies considerably, and that it correlates with the severity of the neurological dysfunction. Remarkably, BMDMs appear to have a beneficial effect on the spinal cord in paresis. In contrast, BMDMs seem to exhibit both beneficial and harmful effects in severe paraplegia.

BACKGROUND The aim of the present study was to assess semi-quantification of myocardial perfusion using adenosine triphosphate (ATP)-stress myocardial perfusion computed tomography (MPCT) in patients with coronary artery disease (CAD). METHODS AND RESULTS Seventeen patients with CAD underwent ATP-stress MPCT, stress myocardial perfusion scintigraphy (MPS) and coronary angiography (CAG). With ATP loading (0.16 mg·kg⁻¹·min⁻¹, 5 min) and slow infusion of contrast medium (2 ml/s, 100 ml), stress images were acquired using prospective electrocardiogram-gated 64-slice CT. Stress MPCT images were analyzed according to the transmural perfusion gradient (TMPG; difference between subendocardial and epicardial attenuation, divided by wall thickness; Hounsfield units [HU]/mm) per segment, and summed TMPG was compared with those of stress MPS and CAG per territory and patient, respectively. There were 36 CAG-proved stenotic vessels in 51 (17 × 3) territories. There were significant correlations between TMPG and MPS stress score per segment, per territory and per patient, respectively (P<0.05). Summed TMPG in territories with and without >70% coronary stenosis was 32.3HU/mm (-1.9~90.9) and 14.5 HU/mm (-5.6~38.4; P<0.05). For detecting coronary artery stenosis, sensitivity, specificity, positive and negative predictive values using the summed TMPG were 72%, 87%, 93% and 57%, in comparison with summed MPS (64%, 73%, 85%, and 46%). CONCLUSIONS Semi-quantification of myocardial perfusion using TMPG has great potential to evaluate the severity of myocardial ischemia, similarly to MPS score.

Hyperthermia is a minimally invasive approach to cancer treatment, but it is difficult to heat only the tumor without damaging surrounding tissue. To solve this problem, we studied the effectiveness of chemohyperthermia with docetaxel‐embedded magnetoliposomes (DMLs) and an applied alternating current (AC) magnetic field. Human MKN45 gastric cancer cells were implanted in the hind limb of Balb‐c/nu/nu mice. Various concentrations of docetaxel‐embedded DMLs were injected into the tumors and exposed to an AC magnetic field ( n = 6, each). For comparison with hyperthermia alone, magnetite‐loaded liposome (ML)‐injected tumors were exposed to an AC magnetic field. Furthermore, the results of DML without AC treatment and docetaxel diluted into PBS with AC treatment were also compared ( n = 10, each). Tumor surface temperature was maintained between 42 and 43°C. Tumor volume was reduced in the DML group with a docetaxel concentration > 56.8 μg/ml, while a docetaxel concentration > 568.5 μg/ml was required for tumor reduction without hyperthermia. Statistically significant differences in tumor volume and survival rate were observed between the DML group exposed to the magnetic field and the other groups. The tumor disappeared in 3 mice in the DML group exposed to the magnetic field; 2 mice survived over 6 months after treatment, whereas all mice of the other groups died by 15 weeks. Histologically, hyperthermia with DML damaged tumor cells and DML diffused homogeneously. To the best of our knowledge, this is the first report to show that hyperthermia using chemotherapeutic agent‐embedded magnetoliposomes has an anticancer effect.

Received April 22, 2010; revised manuscript received May 26, 2010; accepted May 27, 2010; released online July 27, 2010 Time for primary review: 14 days Department of Cardiovascular Surgery, Ehime University Hospital, Toon (F.S., M.N., K.K., M.R., H.I.); Department of Diagnostic and Therapeutic Radiology, Ehime University Graduate School of Medicine, Toon (T.K., T.M.); and Department of Cardiology, Saiseikai Matsuyama Hospital, Matsuyama (K.W.), Japan Mailing address: Mitsugi Nagashima, MD, PhD, Department of Cardiovascular Surgery, Ehime University Hospital, Shitsukawa, Toon 791-0295, Japan. E-mail: mitsugi@aqua.plala.or.jp ISSN-1346-9843 doi: 10.1253/circj.CJ-10-0389 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp Dual-Source Computed Tomography for Visualization of the Abnormal Motion of the Aortic Cusp After Re-Replacement of the Mitral Valve

A 61-year-old man with an intraductal papillary mucinous neoplasm (IPMN) and carcinoma in situ (CIS) of the pancreatic body initially underwent a distal pancreatectomy. Postoperative follow-up included computed tomography (CT) and ultrasonography (US) every 6 months. Intraductal papillary mucinous neoplasm of the pancreatic head was diagnosed 17 months later using peroral pancreatoscopy (POPS) including a biopsy, revealing IPMN with highly dysplastic changes. A total pancreatectomy was therefore performed. The pathological examination revealed IPMN with CIS. The patient was discharged from the hospital and is doing well as of 1 year postoperatively. Although cautious surveillance seems mandatory, consensus has not yet been reached regarding postoperative surveillance. This report presents an unreported case of metachronously arising IPMN with CIS within a relatively early interval, thus suggesting that surveillance every 6 months is preferable to ≥1 year. In addition, endoscopic US, endoscopic retrograde cholangiopancreatography, intraductal US, or POPS should be included in pathological examinations to avoid missing opportunities to treat lesions such as noninvasive IPMN with a good prognosis. Surgically indicated patients with noninvasive recurrence should therefore be strongly considered to undergo a total pancreatectomy.

A partial lower inverted J sternotomy and an extended transseptal incision provide excellent exposure for minimally invasive mitral valve surgery. However, the extended trasnsseptal incision causes dividing the sinus node artery, which may result in conduction system disturbance and need for permanent pacemaker implantation. Therefore, there is a challenge in the patient who requires concomitant ablation for atrial fibrillation because of possible conduction system disturbance caused by extended transseptal incision. We describe a new strategy for combined ablation of atrial fibrillation with minimally invasive cardiac surgery by a transseptal approach to the mitral valve through a partial lower sternotomy incision. Cryoablation was performed using a T-shaped cryoprobe with a lesion set of pulmonary vein isolation and ablation of the left and right isthmus in performing mitral annuloplasty, tricuspid annuloplasty, and atrial septal defect closure through a limited sternotomy incision. This technique might minimize possible conduction system disturbance and provide good surgical result for the patients who undergo mitral valve surgery and ablation of atrial fibrillation.

We report a case of coronary artery bypass grafting through the left thoracotomy in a patient who suffered from sternoclavicular joint infection with methicillin-resistance Staphylococcus aureus. We performed off-pump coronary bypass surgery, using the left internal thoracic artery to the left anterior descending coronary artery and a saphenous vein graft from the aorta to the circumflex artery, with a successful outcome. This approach seems to be safe and effective for coronary bypass grafting in situations where median sternotomy is not favorable, as in the described patient.

Occlusion of the right coronary artery (RCA) ostium by an aortic cusp is a rare anomaly and can be a cause of sudden death. We report the case of a child with progressive stenosis of the right coronary ostium caused by a hypoplastic right coronary cusp that adhered to the aortic wall resulting in severe myocardial ischemia. The patient underwent a Ross-Konno operation with mitral valvuloplasty for congenital aortic valvular stenosis and mitral regurgitation caused by ischemia-induced posteromedial papillary muscle dysfunction. The myocardial ischemia was relieved by resection of the deformed pouch-like cusp to disclose the RCA ostium. Postoperative myocardial scintigraphy demonstrated no myocardial ischemia and multidetector computed tomography showed no coronary ostial stenosis.

Isolated congenital tricuspid regurgitation without downward displacement of the leaflet is uncommon in adults, and repair of such valves often requires a procedure that is more complex than simple tricuspid annuloplasty. We describe a technique of tricuspid valvoplasty using the neo-papillary loop technique to reconstruct multiple artificial chords for isolated congenital tricuspid regurgitation associated with a dysplastic anterior leaflet with agenesis of the chordae tendineae and a hypoplastic anterior papillary muscle. This technique provides a simple and valuable option for the repair of dysplastic valves lacking chordae, even those with a hypoplastic papillary muscle.

Anomalous subaortic left brachiocephalic vein (ASLBV) is a rare systemic venous anomaly. We review our experience with patients associated with ASLBV who underwent cardiac surgery at three institutions. From 1989 to 2009, the medical records of surgically treated patients with ASLBV were analyzed; the incidence of ASLBV, clinical characteristics, and associated anatomical findings were assessed. Fifteen patients had ASLBV. All ASLBVs coursed left lateral to the aortic arch, passed under the ascending aorta anterior to the central pulmonary artery, and joined the right brachiocephalic vein. Fourteen patients had congenital heart disease (CHD), and the remaining patient did not have cardiac anomalies. Its incidence was 0.57% (14 of 2,449) in patients with CHD and only 0.02% (1 of 4,805) in patients without CHD. In patients with CHD, 73.3% (11 of 15) of the patients had conotruncal cardiac anomalies such as tetralogy of Fallot, ventricular septal defect with pulmonary atresia, truncus arteriosus, and interruption of the aortic arch. Eight patients had aortic arch anomalies, including right aortic arch and cervical aortic arch. The deletion of chromosomal 22q11.2 was confirmed in two patients, and one patient was diagnosed with DiGeorge syndrome. ASLBV was clinically silent even without any surgical intervention. ASLBV is a very rare anomaly and is highly associated with conotruncal cardiac anomalies and aortic arch anomalies, including right aortic arch and cervical aortic arch. Preoperative diagnosis is important when any surgical interventions are intended, especially, in patients with conotruncal cardiac anomalies. Clin. Anat. 23:950–955, 2010. © 2010 Wiley‐Liss, Inc.

There have so far been few reports of the pharmacokinetics of oxaliplatin in patients with renal impairment. This report describes the nephrotoxicity induced by repeated cycles of oxaliplatin in a Japanese colorectal cancer patient with moderate renal impairment(creatinine clearance(Ccr): 20-30mL/min). The patient was a 77-year-old male who had chronic renal impairment and received the modified FOLFOX6 repeated every 2 weeks. In cycle 8, the blood concentration of oxaliplatin(66 mg/m2)was measured as the platinum level to confirm the patient's safety. The serum ultrafiltrate concentrations of platinum were 800, 1, 000, 300, <200, and <200 ng/mLat 1, 2, 3 hr, 1 week, and 2 weeks after the start of infusion, respectively, which were closely comparable with the population pharmacokinetic data in Japanese patients with normal renal function. On the other hand, the serum creatinine value was gradually increased after cycle 6, resulting in a decrease of Ccr. The mean Ccr during day 1-59 and day 240-299were significantly different at 26. 5+/-2. 8(mean+/-SD)and 9. 6+/-1. 9mL/min, respectively. Consequently, the chemotherapy showed a complete response after 10 cycles, but the patient got dialysis on day 311. In conclusion, the repeated cycles of oxaliplatin cumulatively damaged the renal function in a Japanese patient with a moderate renal impairment.