We report the case of a 55-year-old woman with aortitis syndrome. She was admitted to our hospital because of repeated chest pain and syncope. An electrocardiogram and the laboratory data suggested acute myocardial infarction, and coronary angiography showed severe bilateral coronary ostial stenosis. No valvular disease was observed. Aortitis syndrome was suspected because of the stenosis of the brachiocephalic artery in addition to the bilateral coronary ostial stenosis, while the patient did not have elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Coronary artery bypass grafting was performed, and the patient's postoperative course was uneventful. However, she again experienced chest pain 9 months after surgery due to aortic regurgitation (AR) and diffuse narrowing change of the left internal thoracic artery graft. Aortic valve replacement and Re-CABG was performed, and the patient was treated with steroid therapy postoperatively. The postoperative course was uneventful, but the patient thereafter died due to bleeding of a malignant adrenal tumor at 21 months after the second surgery.

We report 4 cases of aortic graft replacement for Kommerell diverticulum (KD) and the aberrant subclavian artery (ASA). In two patients who had a right-sided aortic arch, KD and the left ASA, we performed descending aorta replacement and in-situ reconstruction of the left ASA via a right lateral thoracotomy. Third patient had a left-sided aortic arch, KD and the right ASA, in whom we performed descending aorta graft replacement via a left lateral thoracotomy with ostial closure of the right ASA. Fourth patient had a left-sided aortic arch, KD and the right ASA, and complicated by acute type A aortic dissection. We performed a total arch repair with frozen elephant trunk procedure via a median sternotomy. All 4 patients survived operations and discharged from the hospital with symptom relief. The choice of approach, a thoracotomy or a median sternotomy, should be based on patient-specific anatomy and extent of graft replacement.

We present herein a case of disc fracture of a Björk-Shiley valve prosthesis in the mitral position. A 69-year-old woman was admitted to our hospital with a sudden onset of dyspnea followed by deep shock. An echocardiography showed a severe degree of mitral regurgitation and moderate degree of tricuspid regurgitation. Forty-three years previously she had undergone a mitral valve replacement (MVR) for stenosis with the original version of a Björk-Shiley valve prosthesis in another institute. Emergency redo MVR was performed with a bioprosthesis and tricuspid annuloplasty with a semirigid ring. The disc of the extracted Björk-Shiley valve was found to have escaped from the metal housing with two intact struts. Although Björk-Shiley valve dysfunction due to Delrin disk abration has been rarely reported, complete disk fracuture is extremely rare. The important role of regular echocardiographic follow-up should be emphasized to prevent fatal valve fracture.

A 59-year-old woman with a history of pulmonary and cardiac sarcoidosis was admitted to our hospital because of acute femoral artery occlusive diseases. Preoperative echocardiography showed diffuse hypokinesis and biventricular tumors. Transesophageal echocardiography revaealed mobile biventricular tumors. The tumors which consisted of organized thrombi were successfully excised. She was discharged 23 days after surgery. This suggested that hypokinesis accompanying cardiac sarcoidosis caused the biventricular thrombi.

A 69-year-old woman, who had undergone a right nephrectomy for renal tuberculosis in her teens, was admitted with a low grade fever, anorexia and progressive dyspnea. Transthoracic echocardiography showed cardiac tamponade and chest CT revealed an enlarged ascending aorta. She was treated with pericardiocentesis. Specimens of pericardial effusion failed to demonstrate any acid-fast bacilli, but they did reveal a high level of adnosine deaminase (72 IU/l). A diagnosis of tuberculous pericarditis was considered, and antituberculous chemotherapy was started. However, he presented with severe back pain 32 days later and CT revealed type A acute aortic dissection. We therefore replaced the ascending aorta and aortic root. A histopathological examination of the ascending aorta revealed evidence of a granulomatous inflammatory reaction with Langhans giant cells. She thereafter received antituberculous chemotherapy with 4 drugs for 2 months, with continued rifampicin and isoniazid treatment. There was no evidence of any graft infection after 70 days.

A sinus of Valsalva aneurysm is a rare cardiac disorder, and reports of it with an anomalous origin of the coronary artery are scarce. A 35-year-old male was admitted to our department with fatigue and cough. Multi-detector-row computer tomography (MDCT) revealed an isolated extracardiac right sinus of Valsalva aneurysm with an anomalous origin of the left circumflex artery (LCX) and total occlusion of the right coronary artery (RCA). Its diameter was about 70 mm. We performed a partial aortic root remodeling procedure with a trimmed J-graft because he had neither aortic regurgitation (AR) nor annuloaortic ectasia (AAE). Concomitantly, coronary artery bypass grafting to the RCA (Seg. 3) using a saphenous vein, and reconstruction of the LCX by Piehler's technique using a saphenous vein were added. The patient's postoperative course was uneventful, and he was discharged on the 28th postoperative day. Postoperative MDCT revealed that the aneurysm of the right sinus of Valsalva was not enhanced, and the RCA and LCX were patent. This procedure preserved the patient's own normal aortic valve and sinus of Valsalva and enables him to have more physiologically normal hemodynamics than aortic root reconstruction using a composite graft, e.g. Bentall procedure, Cabrol procedure, although the potential progression of the AR requires careful follow-up.

A 74-year-old man undergone mitral valve plasty. After cessation of cardiopulmonary bypass, bleeding persisted from the cardioplegia injection site and dilatation of the ascending aorta with discoloration was observed. The diagnosis of type A aortic dissection extending to the descending aorta was made by transesophageal echocardiogram. Replacement of the ascending aorta was performed under deep hypothermic circulatory arrest. The postoperative course was uneventful. The false lumen of the aortic arch and descending aorta was thrombosed completely on postoperative computed tomography. Intraoperative aortic dissection is a rare but fatal complication of cardiopulmonary bypass. Prompt recognition and appropriate surgical management are of prime importance.

BACKGROUND AND PURPOSE: This study compared the muscle thickness (MT) and echo intensity (EI) of the abdominal, thigh, and lower leg muscles between the paretic and nonparetic sides in chronic stroke survivors. METHODS: Thirty-two stroke survivors living in the community participated in this study. The MT and EI, which are indicators of muscle mass and intramuscular fat or connective tissue, were assessed in the rectus abdominis, external oblique, internal oblique, transversus abdominis, rectus femoris, vastus intermedius, vastus lateralis, vastus medialis, tibialis anterior, gastrocnemius, and soleus via transverse ultrasound imaging. In addition, a possible indicator of physical activity—the frequency of going out per week—was evaluated. RESULTS: All quadriceps muscles and the tibialis anterior were significantly thinner and the EI values of the vastus intermedius, vastus lateralis, vastus medialis, and soleus were significantly higher in the paretic limb than the nonparetic limb. The MT and EI values of abdominal muscles did not differ significantly between the two sides. The MT values of the paretic rectus femoris, vastus lateralis, and vastus medialis were significantly associated with the frequency of going out after adjusting confounding factors. The MT of the nonparetic vastus lateralis was significantly associated with latency from stroke onset after adjusting confounding factors. CONCLUSIONS: Our results indicate that quantitative and qualitative changes on the paretic side in stroke survivors were the most robust in the thigh muscles, whereas such changes might not occur in the abdominal muscles.
Abdominal Muscles ; Connective Tissue ; Extremities ; Humans ; Leg ; Lower Extremity* ; Muscles* ; Quadriceps Muscle ; Rectus Abdominis ; Stroke* ; Survivors* ; Thigh ; Ultrasonography

Background: and Purpose The objective of this study was to identify 2-year longitudinal changes in the muscle thickness (MT) and echo intensity (EI) of the abdominal, thigh, and lower limb muscles in chronic stroke survivors. Methods: This study included 15 chronic stroke survivors aged 74.1±9.9 years. The MT, EI, and subcutaneous fat thickness values of the following muscles on the paretic and nonparetic sides were assessed on transverse ultrasound images: rectus abdominis, external oblique, internal oblique, transversus abdominis, rectus femoris (RF), vastus intermedius, vastus lateralis (VL), vastus medialis, tibialis anterior, gastrocnemius, and soleus. The ultrasound measurements were performed both at baseline and 2 years later. Results: After 2 years, the VL on the paretic side showed a significant decrease in MT (p= 0.031) and increase in EI (p=0.002), whereas the RF on the nonparetic side showed a significant decrease in EI (p=0.046). Correlation coefficient analyses showed that changes in MT (r= 0.668, p=0.012) and EI (r=0.597, p=0.018) of the VL on the paretic side were significantly associated with a change in the body mass index. Conclusions The findings of this longitudinal study suggest that the VL on the paretic side is subject to deteriorations in muscle quantity and quality, and conversely that the RF on the nonparetic side shows an improvement in muscle quality after 2 years in chronic stroke survivors

Aim of the present study was to statistically evaluate the examination rule with use of a questionnaire obtained from physicians regarding treatment for chillness of the limbs, and to prove the clinical usefulness of the database. The database showed that tokishigyakukagoshuyushokyoto was the most frequently used to treat chillness of the limbs, and subsequently keishikajutsubuto, hachimijiogan, and tokishakuyakusan were ranked as drugs with wide use. When physicians determined a kampo formulation suitable for each patient, they used findings specific for the kampo formulation, but not uniform findings obtained from the four traditional examination methods (i.e., inspection, listening and smelling, interviewing, palpitation). There was a statistical difference in the selection mode of drugs among physicians. In a simulation obtained from a questionnaire, there was a positive association between time (time X) to the start of becoming physically warm in the limbs, and time (time Y) to remission (R² = 0.971, P = 0.014). The formula (Y = 4.379 X−0.519), which could predict time Y on the basis of information on time X, was able to accurately monitor the clinical courses of 7 responders to treatment for chillness of the limbs. Taken together, these results strongly suggest that the database constructed in the present study may be useful for evaluation of traditional Kampo medicine, and might allow us to perform more fittingly personalized Kampo medicine in the near future.