Endovascular treatment for chronic aortic dissection in patients with Marfan syndrome is still controversial. A 60-year-old man developed an extended chronic type B dissection involving the aortic arch and thoraco-abdominal aorta with a large entry at the distal aortic arch and patent false lumen. He had undergone David procedure for type A aortic dissection at age 42, and aortic valve replacement for recurrent aortic valve insufficiency at 58, which was complicated with mediastinitis. He also suffered drug-induced interstitial pneumonitis. Considering his complicated surgical history and impaired pulmonary function, conventional graft replacement of thoraco-abdominal aorta was thought to be quite a high risk. Thus, we chose debranch TEVAR with a staged approach. First, debranching and Zone 0 TEVAR with the chimney technique were performed. Then, 4 months later, abdominal debranching and TEVAR was performed. The patient tolerated both procedures well and was discharged home. Two years after last procedure, he is in good condition and computed tomography shows that complete entry closure and false lumen had thrombosed. This strategy may be worthy to be considered even for a patient with Marfan syndrome, in case the patient's condition is unsuitable for conventional surgery.

A 79-year-old man, who had a history of intravesical instillations of bacillus Calmette-Guérin (BCG) therapy for urinary bladder cancer, developed bloody sputum 4 years after BCG therapy. BCG was detected from the sputum by detailed examination. Medical therapy for tuberculosis (TB) was started, but bloody sputum continued. Computed tomography (CT) for the chest was performed to evaluate the state of TB, and surprisingly, found impending rupture of tuberculosis mycotic thoracic aneurysm. He was emergently transferred to our hospital. CT revealed that the aneurysm made a lump with surrounding lung and lymph nodes. It seemed to be quite difficult to dissect and to be quite high risk to perform graft replacement with pneumonectomy. On the other hand, TB infection was controlled with antibiotic therapy. Thus we chose debranch TEVAR for this complicated situation. His bloody sputum regressed soon after the procedure and disappeared during his hospitalization. He was discharged home on POD 13 without serious complication and continued to have antibiotic therapy under the instruction of his primary physician.

This study investigated the effects of exercise intervention with a 12-week slightly-weighted shoe on lower-limb skeletal muscle and gait patterns in the elderly. A total of 29 healthy elderly Japanese who had irregular walking habits were randomly assigned to either slightly-weighted-shoe (WS group, n = 14; Age, 70.6 ± 5.7 years; WS, 493 g) or normal-shoe (NS group, n = 15; Age, 69.3 ± 6.9 years; NS, 293 g) intervention groups. The participants were instructed to maintain their normal daily physical activity (PA) during the intervention period. Segmental intracellular water (ICW) and muscle thickness (MT) were measured as an index of skeletal muscle mass in the lower limb, and kinematic gait data were acquired by motion analysis. Walking stability was assessed as a standard deviation of the vertical fluctuation in whole-body center of mass (COM fluctuation). The daily PA was monitored using an accelerometer and an activity record. ICW in the upper leg and MT of rectus femoris increased significantly in the WS group compared with the NS group (ICW: 13.8% vs. 2.2%, MT: 12.1% vs. 1.3%), while COM fluctuation was significantly reduced in the WS group (p<0.05) during normal walking. The present study demonstrated that interventions with a slightly-weighted-shoe may be able to increase muscle volume in the upper leg and change gait patterns in the healthy elderly.

Protamine has been widely used as a pharmaceutical product and natural food preservative. However, few studies have been conducted to assess the beneficial function of dietary protamine. This study examined the effects of dietary salmon protamine on serum and liver lipid levels and the expression levels of genes encoding proteins involved in lipid homeostasis in the liver of rats. Groups of male Wistar rats were fed AIN93G diet containing 2% or 5% protamine. After 4 weeks of feeding these diets, markedly decreased serum and liver cholesterol (CHOL) and triacylglycerol levels were noted. Increased activity of liver carnitine palmitoyltransferase-2 and acyl-CoA oxidase, which are key enzymes of fatty acid beta-oxidation in the mitochondria and peroxisomes, was found in rats fed on protamine. Furthermore, rats fed protamine showed enhanced fecal excretion of CHOL and bile acid and increased liver mRNA expression levels of ATP-binding cassette (ABC) G5 and ABCG8, which form heterodimers and play a major role in the secretion of CHOL into bile. The decrease in triacylglycerol levels in protamine-fed rats was due to the enhancement of liver beta-oxidation. Furthermore, rats fed protamine exhibited decreased CHOL levels through the suppression of CHOL and bile acid absorption and the enhancement of CHOL secretion into bile. These results suggest that dietary protamine has beneficial effects that may aid in the prevention of lifestyle-related diseases such as hyperlipidemia and atherosclerosis.
Absorption ; Acyl-CoA Oxidase ; Animals ; Atherosclerosis ; Bile ; Carnitine ; Cholesterol ; Diet ; Homeostasis ; Humans ; Hyperlipidemias ; Lipid Metabolism ; Liver ; Male ; Mitochondria ; Peroxisomes ; Proteins ; Rats ; Rats, Wistar ; RNA, Messenger ; Salmon ; Triglycerides

A 67-year-old man developed the recurrence of postoperative constrictive pericarditis. He had two operation histories : the one was CABG for old myocardial infarction and the other was pericardiectomy for postoperative pericarditis at 57 and 59 years old respectively. Both operations were performed in our hospital. We used an ePTFE sheet for covering the heart in the pericardiectomy. The course post operation was good, but eight years after the pericardiectomy, he had abdominal distension and leg edema. Detailed studies revealed a recurrence of constrictive pericarditis, and reoperation was performed. The re-operative finding showed thickened sclerotic tissues on both sides of an ePTFE sheet which was applied to the cardiac surface during the previous surgery. No abnormal tissue was detected where the ePTFE sheet was not applied. The ePTFE sheet and the sclerotic tissues were removed under cardiopulmonary bypass support, and then diastolic dysfunction improved dramatically. His chest was closed without applying an ePTFE sheet. His post-operative course was uneventful and he was discharged on the 20th postoperative day. The ePTFE sheet was highly suspected as a cause of the recurrent constrictive pericarditis. An ePTFE sheet-induced constrictive pericarditis should be considered as one of the postoperative complications even in the mid and long-term period. The ePTFE sheet is useful for preventing heart or vascular injury when we perform resternotomy, but in rare cases, there is some possibility of association with a risk of pericarditis.

Mitral valve surgeries for cases with mitral annular calcification (MAC) are challenging because of the operative complications. For a case of MS with MAC, we achieved mitral valve plasty by ultrasonic decalcification alone. An 82-year-old male with edema and dyspnea was diagnosed with AS and MS with MAC. MAC was so severe that MVR was challenging. There were calcifications at the anterior commissure and the anterior mitral leaflet (AML), and removal of them was expected to improve the valve function. Therefore, anterior commissurotomy and ultrasonic decalcification of the anterior commissural annulus was performed using cavitron ultrasonic surgical aspiration (CUSA). Following the resection of the aortic valve, we carried out decalcification of the AML through the aortic valve orifice. After AVR, a trans-esophageal echocardiogram showed MS was ameliorated. Two years after surgery, recurrence of MS was not recognized. Some mitral cases with MAC can be treated by only decalcification to avoid risky valve replacement.