A pseudoaneurysm of the ascending aorta is a complication found in aortic valve surgery. A 66-year-old man who had a previous history of aortic valve replacement due to infectious endocarditis was admitted to our hospital suffering from chest pain. Follow-up chest X-ray and transthoracic echocardiogram had revealed no findings of pseudoaneurysm during the intervening period. At admission, computed tomographic scan and transesophageal echocardiogram each showed a Type A acute aortic dissection and a pseudoaneurysm of the ascending aorta. Under cardiopulmonary bypass and deep hypothermic circulatory arrest, an ascending aortic graft replacement was carried out uneventfully. The patient is well 14 months postoperatively. Postoperative examinations following aortic surgery should be performed not only from the view point of cardiac function, but also from that of a pseudoaneurysm.

Homologous blood transfusion may increase generalized inflammation by stimulating a patient's immune system during an open heart operation using cardiopulmonary bypass (CPB). We examined the beneficial effects on lung function of having no homologous blood transfusion during pediatric open heart operations. Thirty-three consecutive patients with ventricular septal defect were divided into (a) an autologous blood transfusion (AB) group (n=16) consisting of patients in whom predonation of autologous blood was undertaken and so homologous blood was not transfused, and (b) a control group (n=17) consisting of patients in whom homologous blood was used with a leukocyte removal filter during and after operation. Patients' age, sex, body weight, and contents of primed solution of the bypass circuit were similar in the 2 groups. Arterial blood gas analysis was carried out several times and the respiratory index (RI) calculated. Postoperative duration of intubation, white blood cell counts, and CRP titer were also compared. RI immediately after CPB did not differ between the AB and control groups, but RIs 3 and 6h after operation were significantly lower in the AB than in the control group (0.43±0.08 vs. 0.79±0.15 and 0.38±0.07 vs. 1.60±0.17). Duration of intubation, white blood cell counts, CRP titer were not statistically different. The results suggest that avoiding transfusion of whole homologous blood elements works effectively for preventing lung dysfunction after CPB.

No abstract available.
Ovarian Neoplasms

A case of combined redo off-pump CABG (OPCAB) with right gastroepiploic artery and abdominal aortic aneurysm repair is reported. A 71-year-old man with a previous history of CABG was admitted for the operation of recurrent angina pectoris and known abdominal aortic aneurysm. Preoperative coronary angiograms showed obstruction of LITA graft for LAD. The operative procedure consisted of redo OPCAB using right gastroepiploic artery as a transdiaphragmatic graft under left antero-lateral thoracotomy and graft replacement of abdominal aortic aneurysm under median laparotomy simultaneously. This strategy has the advantage of avoiding the continuity of median sternotomy and laparotomy and contributes to the minimally invasive procedure in the combined operation.

A 41-year-old man was referred to our hospital suffering from pyrexia. Echocardiogram showed diffuse severe hypokinesis of the left ventricle. The patient was treated medically under a diagnosis of acute myocarditis and anticoagulation therapy had been started. However a large mobile thrombus and multiple small thrombi were detected in the left ventricle 2 days after admission. Because of the deterioration of his left ventricular function (LVEF 14%), he was treated medically with careful monitoring of the thrombi by echocardiogram. His left ventricular function started to improve 3 days after admission (LVEF 27%), and then surgical removal of the thrombi was performed through left ventriculotomy. His postoperative course was uneventful. LVEF was improved to 60% at discharge. He is doing well without any signs of embolic event at 2 years postoperatively. Left ventriculotomy is one of the useful methods for removal of left ventricular thrombus associated with acute myocarditis, if the procedure is performed during the recovery phase.

The results of complete graft replacement for thoracoabdominal aortic aneurysm remains unsatisfactory. The operative strategies, including the method of reconstruction of visceral vessels and the protection of abdominal organs and spinal cord, are controversial. Two male patients (53 and 59 years of age) had thoracoabdominal aortic aneurysms including the celiac artery and small abdominal aortic aneurysm in the renal arterial part. They underwent replacement of a large aneurysm using a Dacron prosthesis with reconstruction of the celiac artery. The remaining small aneurysm was wrapped by a bandage of Teflon tape 3mm in width. This wrapping technique was easy to perform and could be sufficiently adapted to the aneurysm preserving visceral arterial branches. The postoperative courses were uneventful. Their postoperative enhanced CTs (41 months and 26 months after surgery, respectively) revealed no enlargement of the wrapped aortic aneurysm and no stenosis of the visceral branches. This result suggests that our wrapping method is useful to reinforce the wall of small aortic aneurysms.

Objective: The standard dose for pegylated liposomal doxorubicin (PLD) is 50 mg/m2 every 4 weeks. While 40 mg/m2 has recently been used in clinical practice, evidence supporting this use remains lacking. Methods: This phase III randomized, non-inferiority study compared progressionfree survival (PFS) for patients with platinum-resistant ovarian carcinoma between an experimental arm (40 mg/m2 PLD) and a standard arm (50 mg/m2 PLD) until 10 courses, disease progression or unacceptable toxicity. Eligible patients had received ≤2 prior lines.Stratification was by performance status and PFS of prior chemotherapy (<3 months versus ≥3 months). The primary endpoint was PFS and secondary endpoints were overall survival (OS), toxicity profile, clinical response and tolerability. The total number of patients was 470. Results: The trial was prematurely closed due to slow recruitment, with 272 patients randomized to the experimental arm (n=137) and standard arm (n=135). Final analysis was performed with 234 deaths and 269 events for PFS. In the experimental arm vs. standard arm, median PFS was 4.0 months vs. 4.0 months (hazard ratio [HR]=1.065; 95% confidence interval [CI]=0.830–1.366) and median OS was 14.0 months vs. 14.0 months (HR=1.078; 95% CI=0.831–1.397). Hematologic toxicity and oral cavity mucositis (≥grade 2) were more frequent in the standard arm than in the experimental arm, but no difference was seen in ≥grade 2 hand-foot skin reaction. Conclusion Non-inferiority of 2 PLD dosing schedule was not confirmed because the trial was closed prematurely. However, recommendation of dose reduction of PLD should be based both on efficacy and safety.

No abstract available.
Carcinosarcoma*

Purpose: Circulating tumor DNA (ctDNA) is an attractive source for liquid biopsy to understand molecular phenotypes of a tumor non-invasively, which is also expected to be both a diagnostic and prognostic marker. PIK3CA and KRAS are among the most frequently mutated genes in epithelial ovarian cancer (EOC). In addition, their hotspot mutations have already been identified and are ready for a highly sensitive analysis. Our aim is to clarify the significance of PIK3CA and KRAS mutations in the plasma of EOC patients as tumor-informed ctDNA. Methods: We screened 306 patients with ovarian tumors for somatic PIK3CA or KRAS mutations. A total of 85 EOC patients had somatic PIK3CA and/or KRAS mutations, and the corresponding mutations were subsequently analyzed using a droplet digital polymerase chain reaction in their plasma. Results: The detection rates for ctDNA were 27% in EOC patients. Advanced stage and positive peritoneal cytology were associated with higher frequency of ctDNA detection. Preoperative ctDNA detection was found to be an indicator of outcomes, and multivariate analysis revealed that ctDNA remained an independent risk factor for recurrence (p=0.010). Moreover, we assessed the mutation frequency in matched plasma before surgery and at recurrence from 17 patients, and found six patients had higher mutation rates in cell-free DNA at recurrence compared to that at primary diagnosis. Conclusion The presence of ctDNA at diagnosis was an indicator for recurrence, which suggests potential tumor spread even when tumors were localized at the time of diagnosis.