Objectives: The progress of medical care has resulted in a significant increase in the number of elderly people worldwide. However, elderly patients are commonly denied aortic arch surgery due to the perception of poor clinical outcomes. We retrospectively evaluated mid-term clinical outcomes and quality of life (QoL) of octogenarian patients. Methods: Forty-nine consecutive patients aged >80 years were separated into two groups: group S (n = 20) underwent surgical treatment, whereas group M patients (n = 29) were treated medically. Kaplan-Meier survival analysis was performed, and QoL was assessed using the Short-Form 36 questionnaire. Risk factors for mortality were determined using the Cox hazard regression model. Results: Five-year survival was 61.5% in group S and 13.6% in group M (P = 0.02). Freedom from aorta-related death at five years was 92.3% in group S and 32.4% in group M (P = 0.01). The 61.5% survival probability of group S patients at five years was identical to the predictive survival rate of 66.2% calculated from a sex- and age-matched Japanese population, whereas the 13.6% survival probability of group M patients was significantly lower than the predictive survival rate of 66.9% (P < 0 001). Among the mid-term survivors, the QoL of group S patients was equivalent to that of group M patients. Cox hazard regression analysis revealed that only medical therapy was a risk factor for mortality. Conclusions: Aortic arch surgery for octogenarians can yield satisfactory clinical outcomes as well as adequate daily activity. These findings indicate that age alone should not disqualify octogenarian patients from aortic arch intervention.

Background: Tiotropium, a long-acting bronchodilator, can be used perioperatively in patients with lung cancer and airway obstruction, although its benefits for the perioperative outcome remain unclear. Methods: We prospectively collected the perioperative data of 44 patients with resectable lung cancer and untreated airway obstruction. Tiotropium was not used before September 2007 (control group, n = 24) but was used routinely thereafter (treated group, n = 20). We estimated a propensity score to adjust comparisons between the groups. Results: Tiotropium improved preoperative global pulmonary function significantly, especially in four patients. Postoperative outcomes in these major responders were significantly better than those in the remaining minor responders. However, postoperative outcomes were not significantly different between the treated group (n = 15) and the control group (n = 15) matched by a propensity score. Conclusion: Regardless of its favorable effects on preoperative pulmonary function, we could not establish a significant benefit of tiotropium for postoperative outcomes overall. Nonetheless, our data suggested that tiotropium might have improved the postoperative outcomes of major responders.

A 63-year-old woman who had been on hemodialysis for 20 years was referred to our institution to undergo mitral valve surgery for mitral valve stenosis. Intraoperative investigations confirmed severe calcification of the mitral leaflets and mitral annulus. We excised the only anterior leaflet, but preserved the posterior leaflet to prevent a fatal complication such as posterior left ventricular rupture or injury of the coronary artery. We passed 2-0 polyester mattress sutures through the anterior mitral annulus from the left ventricle to the left atrium, and then folded the posterior leaflet. Preserved posterior leaflet was fixed to posterior mitral annulus and prosthetic valve. The mitral valve was replaced using a St. Jude Medical mechanical heart valve with a specific structure, whose hinge shifts to the left atrial side and most of the leaflet to move its housing. This particular structure enables to perform this procedure without the need for excision of a severely calcified posterior mitral leaflet and annulus.

We report 3 cases of subdural hematoma following open heart surgery under cardiopulmonary bypass. In 2 patients, emergency removal and drainage of a subdural hematoma was performed by neurosurgeons, and conservative management was performed in the remaining one. All patients belonged to a high risk group of bleeding due to anticoagulation therapy, and they had no episode of head trauma. Subdural hematomas may have been due to rapid alterations in cerebral volume, leading to a tearing of the dural bridging veins under cardiopulmonary bypass. Although early diagnosis and prompt treatment is very important, it is often difficult to examine neurological findings after cardiac surgery. We consider that patients who need long-term sedation under anticoagulation therapy must have their neurological status checked at least once in a few days.

A 68-year-old man, who had undergone percutaneous coronary intervention for right coronary disease 2 weeks earlier, was admitted to our hospital for investigation of a fever. Blood culture and echocardiography revealed isolated aortic valve infective endocarditis. He was treated with antibiotics for more than 1 week, but echocardiography showed an aortic root abscess with severe aortic regurgitation. Thus, we performed aortic root replacement using an artificial Freestyle stentless bioprosthesis valve. The patient had an uneventful postoperative course and antibiotic treatment was continued for a further 8 weeks.

We report the surgical treatment of coarctation of the aorta (CoA) in 3 adults, 2 women and 1 man, aged between 18 and 32 years old. All of the patients had blood pressure gradients higher than 70 mmHg between the upper and lower limbs. In 2 patients, we simply clamped the aorta and excised the CoA: while in the other patient, we excised the CoA using partial extracorporeal circulation with a femoro-femoral (F-F) bypass. Reconstruction was done by an end to end anastomosis in 2 patients and with an artificial tube graft in 1 patient who regulred the extended aortic arch repair. Postoperatively, the pressure gradients between the upper and lower limbs dropped to below 20 mmHg in intensive care unit (ICU). Two of the patients have now stopped taking antihypertensive drugs and the other patient is taking half the preoperative dose.

A 20-year-old man was admitted with a diagnosis of constrictive pericarditis 6 months after direct closure of atrial septal defect (ASD). He complained of fatigue and dyspnea. Cardiac echo cardiography, computed tomography (CT), magnetic resonance imaging (MRI) and cardiac catheterization suggested pericardial and epicardial constriction. During the operation, the thickened pericardium was peeled off. Multiple longitudinal and transverse incisions were made in the thickened epicardium as reported by waffle. Postoperative hemodynamic state was improved. The cardiac index increased from 1.91 to 3.17 l/min/m2. The pulmonary capillary wedge pressure (PCWP) decreased from 26 to 14 mmHg, although dip and plateau pattern was maintained. The postoperative course was uneventful.

Objective: We sought to evaluate the utility of integrated breath-hold single-photon emission tomography and computed tomography imaging compared with that of simple calculation with the lung segment-counting technique for predicting residual pulmonary function in patients undergoing surgical intervention for lung cancer.Methods: A prospective series of 22 patients undergoing anatomic lung resection for cancer were enrolled in this study. Postoperative residual forced expiratory volume in 1 second was predicted by measuring the radioactivity counts of the affected lobes or segments to be resected within the entire lungs by placement of regions of interest on single-photon emission tomography and computed tomography images. Residual forced expiratory volume in 1 second was also estimated by using the segment-counting technique.Results: Both predicted values agreed well with postoperative forced expiratory volume in 1 second. Although the residual forced expiratory volume in 1 second predicted by means of single-photon emission tomography and computed tomography correlated well with that predicted by using segment counting, the values were significantly underestimated by the segment-counting technique in 4 outliers with severe emphysema. There were 2 patients with borderline pulmonary functional reserve whose residual forced expiratory volume in 1 second values were predicted more accurately by means of single-photon emission tomography and computed tomography than by using segment counting.Conclusion: Integrated breath-hold single-photon emission tomography and computed tomography images allow the accurate prediction of postoperative pulmonary function but without statistical superiority over the simple segment-counting technique. Further study of the usefulness of single-photon emission tomography and computed tomography in patients with severe emphysema and borderline lung function should prove valuable because the segment-counting technique underestimates pulmonary functional reserve in these patients.

BACKGROUND:Left ventricular restoration (LVR) is thought to be effective for ischemic cardiomyopathy (ICM). We assessed the early and mid-term results of overlapping cardiac volume reduction (OLCVR) as an operation for LVR on patients with ICM.METHODS:From February to June 2004, 4 patients with ICM underwent OLCVR in our department.RESULTS:There was no death. Significant decreases in the left ventricular end diastolic volume index and in the left ventricular end systolic volume index were observed in the early postoperative period in all the 4 patients. These effects were still evident 1 year later, with improved New York Heart Association (NYHA) functional class and a smaller left ventricular diastolic diameter. One patient required implantation of a cardioverter defibrillator 16 months postoperatively.CONCLUSION:The favorable early and mid-term results of the OLCVR indicate that it is an effective procedure for patients with ICM.

Using Zucker fatty rats, a strain characterized by diabetes and hyperlipidemia, we investigated the diabetes- and hyperlipidemia- related impairment of bone marrow mononuclear cells (BMCs) for inducing therapeutic angiogenesis. BMCs from Zucker fatty and normal Zucker lean rats were collected and cultured. Although the characterization and cell survival of BMCs did not differ, the VEGF production, endothelial differentiation, and endothelial cell colony-forming potential of BMCs from Zucker fatty rats were significantly lower than those of BMCs from lean rats. By using an ischemic hindlimb model, we found that the native recovery of induced limb ischemia in the Zucker fatty rats was also significantly worse than that in the lean rats. Furthermore, the expression of 5-hydroxytryptamine (5-HT2A) receptors was obviously higher in the Zucker fatty rats than that in the lean rats and was enhanced after limb ischemia. Although the therapeutic potency was lower than with the implantation of BMCs from normal lean rats, the implantation of BMCs from fatty rats could also induce angiogenesis and increase blood flow significantly in the ischemic hindlimbs of Zucker fatty rats. Furthermore, the blood flow in the ischemic hindlimbs was increased by the administration of sarpogrelate, a selective 5-HT2A-receptor antagonist. Our results clearly show diabetes- and hyperlipidemia- related dysfunction and impaired potency for inducing angiogenesis of BMCs. However, the implantation of autologous BMCs into ischemic limbs of diabetic and hyperlipidemic rats has induced therapeutic angiogenesis effectively, and blood flow would be enhanced by the administration of a 5-HT2A-receptor antagonist.

STUDY OBJECTIVES:To determine the ability of quantitative CT, with special reference to area of emphysema, to predict early postoperative oxygenation capacity and outcome after lung lobectomy for cancer.METHODS:Sixty-two consecutive patients scheduled to undergo lung lobectomy for cancer were enrolled in this study. The area of emphysema (< - 910 Hounsfield units) was measured on a three-dimensional CT lung model. Arterial oxygen saturation (Sao(2)) was calculated from Pao(2) measured 1 day before and 1 day after surgery with patients at rest breathing room air. A patient was considered to have recovered at the completion of a standardized management regimen.RESULTS:Postoperative Sao(2) (postSao(2)) was predicted by the baseline value and the area of emphysema with the use of a regression equation. Ten of the 62 patients (16%) had postoperative cardiopulmonary complications (CPCs). The median time to postoperative recovery was 3 days (range, 1 to 17 days). Predicted postSao(2) and predicted postoperative FEV(1) were shown to be significant independent predictors of postoperative CPCs as well as postoperative recovery time.CONCLUSION:Determining the area of emphysema by quantitative CT is useful in predicting early postoperative oxygenation capacity. Predicted oxygenation capacity and predicted ventilatory capacity independently affect perioperative outcomes. Therefore, using quantitative CT in combination with spirometry may improve risk prediction in patients undergoing lung lobectomy for cancer. However, the role of quantitative CT in grading nonemphysematous lung diseases, such as interstitial lung diseases, must be investigated.

A 20-year-old man was admitted to our hospital with a sudden onset of dyspnea, caused by right pleural effusion. The patient was in a state of shock. Thoracentesis was revealed hemothorax. Right thoracotomy revealed pulmonary arteriovenous fistula projecting into the intrapleural space from the right upper lobe. Partial resection was performed. His postoperative course was uneventful. Intrapleural rupture of pulmonary arteriovenous fistula was reported rarely; therefore we described here our case.

Objective: To establish a technique for performing isolated lung perfusion (ILP) under video-assisted thoracic surgery (VATS) to treat unresectable lung malignancies. Methods: Under fluoroscopic and thoracoscopic guidance, five canine left lungs were isolated by means of an endovascular technique comprising pulmonary artery cannulation through the right femoral. vein and pulmonary vein cannulation through the left auricular appendage (VATS-ILP). ILP was performed for 20 min at a flow rate of 30 ml/min with a high-dose cisplatin solution (50 mu g/ml). Toxicity and pharmacokinetics of VATS-ILP were compared with those of conventional ILP performed in five additional lungs. Results: VATS-ILP was performed safety without adverse reaction. Both VATS-ILP and conventional ILP delivered a high dose of cisplatin to the treated lung (total platinum concentration: 48 +/- 17 mu g/g tissue for VATS-ILP vs. 51 +/- 19 mu g/g tissue for conventional ILP, P > 0.1) without significant systemic leakage (total platinum concentration: 0.4 +/- 0.1 mu g/ml. plasma vs. 0.5 +/- 0.2 mu g/ml plasma, P > 0.1). In addition, no significant differences were observed between the groups in the serum lactate dehydrogenase level, serum angiotensin-converting enzyme level, body weight change, or mid-term histological change following ILP. A significantly smaller thoracotomy was used for VATS-ILP than for conventional. ILP (4.7 +/- 0.4 cm for VATS-ILP vs. 12 +/- 0.7 cm for conventional ILP, P < 0.001) because VATS-ILP required neither arteriotomy nor venotomy. Conclusions: We established a canine VATS-ILP model. that showed pharmacokinetic potential similar to that of conventional ILP. A clinical trial of VATS-ILP with cytotoxic drugs is warranted. (c) 2005 Elsevier B.V. All rights reserved.

The surgical treatment for thrombosed type A aortic dissection is controversial. We treated 15 cases (28.8%) with thrombosed type A acute aortic dissection among 52 cases of all type A acute aortic dissection during past 7 years and 8 months. Nine cases was treated conservatively and 6 cases received emergent operation due to cardiac tamponade, shock, and ulcer-like projection (ULP) in the ascending aorta (> 50 mm). In the group of conservative therapy, 2 cases in which the ascending aorta was enlarged (54, 60 mm), was converted to operation in the acute phase because of further enlargement of ascending aorta and increase of cardiac effusion. The other patients (aortic diameter: 40-46 mm) who received conservative therapy were well controlled by medical therapy in the early and late phase except 1 who died suddenly in the follow-up. There was no mortality and late death in the operated patients. From these results, we conclude that thrombosed type A aortic dissection in which the diameter of ascending aortic aorta is larger than 50 mm, have cardiac tamponade and ULP in the ascending aorta might needs operation.

We report 2 cases of cardiovascular disease related to end-stage syphilitic infection, which is now relatively rare. A 49-year-old man (case 1), and a 45-year-old man (case 2) were admitted to our hospital for angina pectoris. Cardiac catheterization showed severe aortic regurgitation and left coronary ostial stenosis. Active syphilis was detected in both cases by routine blood examination on admission. Oral ampicillin was started immediately to treat the syphilis; however, during the course of treatment, acute heart failure developed in both patients. We performed emergency aortic valve replacement and coronary artery bypass grafting. Intraoperatively, the orifice of the left coronary artery was almost occluded, and retrograde perfusion of cardioplegia was needed to induce cardiac arrest. Both patients recovered uneventfully. When treating patients with antibiotics for syphilitic disease, it is important to prepare for the possibility of urgent surgery.

Objectives: Using cell-based therapy to induce therapeutic angiogenesis has been the focus of much recent attention. We used freshly collected CD117-positive stem cells (CD117(+) cells) and ex vivo expanded CD117(+) cells to investigate the role of cellular expression of several adhesion molecules in this therapeutic regimen.Methods: CD117(+) cells were separated from the bone marrow mononuclear cells of C57/BL6 mice and cell expansion was done by 2 weeks of cultivation. The cellular expression of integrin-beta(1), integrin-beta(3) and VE-cadherin was analyzed by Western blot and real-time PCR. Three-dimensional culture was performed to observe the capillary-like tube formation. We also implanted cells into the ischemic limbs of mice and evaluated the survival and incorporation of these implanted cells and measured the blood flow and microvessel density of the ischemic limbs 2 weeks after treatment.Results: The expression of integrin-beta(1) in the expanded cells decreased significantly, to about 30% of the freshly unexpanded CD117(+) cells. However, the expression of integrin-beta(3) did not change significantly and the VE-cadherin increased after ex vivo expansion of the CD117(+) cells. Antibody perturbation to integrin-beta(1) significantly inhibited the adhesion, growth and tube formation of cultured CD117(+) cells. Furthermore, the freshly unexpanded CD117(+) cells survived well and were incorporated in microvessels after implantation into the ischemic limbs of mice, resulting in a significant increase in blood flow and microvessel density. The cell survival and incorporation decreased, and the angiogenic potency was deprived by antibody perturbation to integrin-beta(1) before implantation. Conversely, these expanded cells had weak angiogenic potency because of the poor cell survival and incorporation after implantation, but the increase in integrin-beta(1) expression by subjecting them to 24-h hypoxia prestimulation increased cell survival and angiogenic potency significantly after implantation into the ischemic limbs.Conclusion: These data clearly show that integrin-beta(1) is a critical adhesion molecule for inducing therapeutic angiogenesis in cell-based therapy, by regulating cell survival and differentiation after implantation into ischemic tissue. (C) 2004 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

A 73-year-old man was admitted for investigation of back pain, blood-stained sputum, and a high fever. Computed tomography (CT) showed a pseudoaneurysm in the descending aorta and intravenous antibiotic therapy was begun immediately after blood had been taken for culture. However, his temperature continued to spike daily, up to 38 degrees C, and his CRP was also elevated. The blood cultures were negative. The aneurysm ruptured and we replaced the descending aorta with a rifampicin (RFP)-soaked vascular prosthesis, and wrapped it with greater omentum. Postoperative antibiotic therapy with vancomycin hydrochloride, RFP, and amikacin sulfate was continued for 8 weeks. The patient recovered uneventfully. Thus, an infected aneurysm was effectively treated with a RFP-soaked vascular prosthesis and omentopexy.

We report a case with pericardial diverticulum in the mediastinum. A 64-year-old woman visited our hospital because of cough and dyspnea. Chest X-ray showed a smooth-bordered mass in the right superior mediastinum and computed tomography (CT) showed a homogeneous cystic mass in the paratracheal area. During right mini-thoracotomy, a thin-walled cystic lesion was found involving the trachea, the superior vena cava, and the azygos vein. The cyst extended a duct toward the pericardium. We performed total excision and pathological examination confirmed the diagnosis of a pericardial diverticulum. Mini-thoracotomy provides an effective and minimally invasive means of excising the mediastinal mass, relieving symptoms, and allowing pathological examination.

Successful CABG revascularization is still the most effective treatment for severe myocardial ischemia. Unfortunately, satisfactory result is not achieved in some patients due to incompletely revasculization or extreme left ventricular (LV) dilation, and new strategies are asked to develop. We tried to increase their outcome by combination therapy with CABG and neovascularization or surgical ventricular restoration (SVR).