A 77-year-old woman presented three months after an inferior myocardial infarction with congestive heart failure, a 7-mm posterior ventricular septal rupture (VSR), moderate functional mitral and tricuspid regurgitation, and critical stenoses of the right coronary and circumflex arteries. To avoid a ventriculotomy, we repaired the defect through a trans-tricuspid right-atrial approach using a double 25×25 mm bovine-pericardial patch secured with eight 4-0 polypropylene vertical mattress sutures. Two-vessel coronary artery bypass grafting was completed on the beating heart, followed by mitral and tricuspid annuloplasty. Cardiopulmonary bypass and aortic cross-clamp times were 231 and 113 min, respectively. The postoperative course was uneventful without mechanical circulatory support. Echocardiography confirmed complete closure of the VSR and elimination of both valvular regurgitations, and the patient was discharged home on postoperative day 30. This case illustrates that a trans-tricuspid double-patch technique can achieve secure closure of chronic posterior VSR while preserving ventricular function and permitting simultaneous valve repair and revascularization.

Background/Aims: Mechanical properties (MPs) and axial and radial force (AF and RF) may influence the efficacy and complications of self-expandable metallic stent (SEMS) placement. We measured the MPs of various SEMSs and examined their influence on the SEMS clinical ability. Methods: We evaluated the MPs of 29 types of 10-mm SEMSs. RF was measured using a conventional measurement device. AF was measured using the conventional and new methods, and the correlation between the methods was evaluated. Results: A high correlation in AFs was observed, as measured by the new and conventional manual methods. AF and RF scatterplots divided the SEMSs into three subgroups according to structure: hook-and-cross-type (low AF and RF), cross-type (high AF and low RF), and laser-cut-type (intermediate AF and high RF). The hook-and-cross-type had the largest axial force zero border (>20°), followed by the laser-cut and cross types. Conclusions MPs were related to stent structure. Hook-and-cross-type SEMSs had a low AF and high axial force zero border and were considered safest because they caused minimal stress on the biliary wall. However, the increase in RF must be overcome.

Pericardial pacing wire placement may occasionally result in intravascular or intratracheal wire migration, infective endocarditis, and sepsis; reportedly, the incidence of complications is approximately 0.09 to 0.4%. We report a case of a retained epicardial pacing wire that migrated into the pulmonary artery. A 66-year-old man underwent coronary artery bypass grafting for angina pectoris, with placement of an epicardial pacing wire on the right ventricular epicardium, 6 years prior to presentation. Some resistance was encountered during wire extraction; therefore, it was cut off at the cutaneous level on postoperative day 8. Computed tomography performed 6 years postoperatively revealed migration of the pacing wire into the pulmonary artery, and it was removed using catheter intervention. Surgeons should be aware of complications associated with retained pacing wires in patients in whom epicardial wires are retained after cardiac surgery.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic disease characterized by suprapubic pain and lower urinary tract symptoms. Perhaps because of the heterogeneous nature of this disease and its multifactorial etiology, clinical trials in allinclusive populations of IC/BPS patients without phenotyping in the last decade have mainly failed to discover new therapeutic modalities of IC/BPS. Thus, phenotyping IC/BPS, aimed at identifying bladder-centric and/or bladder-beyond pathologies, including cystoscopic observation of Hunner or non-Hunner lesions of the bladder mucosa, is particularly important for the future of IC/BPS management. Based on recent discussions at international conferences, including the International Consultation on IC, Japan, it has been proposed that Hunner-lesion IC should be separated from other non-Hunner IC/BPS because of its distinct inflammatory profiles and epithelial denudation compared with non-Hunner IC/BPS. However, there are still no standard criteria for the diagnosis of Hunner lesions other than typical lesions, while conventional cystoscopic observations may miss atypical or small Hunner lesions. Furthermore, diagnosis of the bladder-centric phenotype of IC/BPS requires confirmation that identified mucosal lesions are truly a cause of bladder pain in IC/BPS patients. This review article discusses the current status of IC/BPS pathophysiology and diagnosis, as well as future directions of the proper diagnosis of bladder-centric IC/BPS, in which pathophysiological mechanisms other than those in inflammatory pathways, such as angiogenic and immunogenic abnormalities, could also be involved in both Hunner-lesion IC and non-Hunner IC/BPS. It is hoped that this new paradigm in the pathophysiological evaluation and diagnosis of IC/BPS could lead to pathology-based phenotyping and new treatments for this heterogeneous disease.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic disease characterized by suprapubic pain and lower urinary tract symptoms. Perhaps because of the heterogeneous nature of this disease and its multifactorial etiology, clinical trials in allinclusive populations of IC/BPS patients without phenotyping in the last decade have mainly failed to discover new therapeutic modalities of IC/BPS. Thus, phenotyping IC/BPS, aimed at identifying bladder-centric and/or bladder-beyond pathologies, including cystoscopic observation of Hunner or non-Hunner lesions of the bladder mucosa, is particularly important for the future of IC/BPS management. Based on recent discussions at international conferences, including the International Consultation on IC, Japan, it has been proposed that Hunner-lesion IC should be separated from other non-Hunner IC/BPS because of its distinct inflammatory profiles and epithelial denudation compared with non-Hunner IC/BPS. However, there are still no standard criteria for the diagnosis of Hunner lesions other than typical lesions, while conventional cystoscopic observations may miss atypical or small Hunner lesions. Furthermore, diagnosis of the bladder-centric phenotype of IC/BPS requires confirmation that identified mucosal lesions are truly a cause of bladder pain in IC/BPS patients. This review article discusses the current status of IC/BPS pathophysiology and diagnosis, as well as future directions of the proper diagnosis of bladder-centric IC/BPS, in which pathophysiological mechanisms other than those in inflammatory pathways, such as angiogenic and immunogenic abnormalities, could also be involved in both Hunner-lesion IC and non-Hunner IC/BPS. It is hoped that this new paradigm in the pathophysiological evaluation and diagnosis of IC/BPS could lead to pathology-based phenotyping and new treatments for this heterogeneous disease.

A man in his fifties was diagnosed with retrograde type A acute aortic dissection. He underwent total arch replacement using the Gelweave Lupiae graft and staged thoracic endovascular aortic repair. Five days after discharge from the hospital, he was referred to our institution because of severe hemolytic anemia. Electrocardiography-gated computed tomography angiography demonstrated significant kinking of the graft adjacent to the proximal anastomotic site. Cine cardiac magnetic resonance imaging showed that graft kinking deteriorated during systole. We concluded that his hemolytic anemia was caused by graft kinking and surgical repair was required. The graft was transected at the kinking site and then reconstructed. After surgical repair, the hemolytic anemia improved immediately.

Background/Aims: Esophageal motility disorders (EMDs) contribute to the pathophysiology of gastroesophageal reflux disease. However, the causes of EMDs and their impact on gastroesophageal reflux disease-associated symptoms remain unknown. This study aims to elucidate clinical features associated with various types of EMDs in patients with heartburn symptoms. Methods: Of the 511 patients who underwent high-resolution manometry, 394 who were evaluated for heartburn symptoms were examined. Patients subjected to high-resolution manometry were classified into 4 groups: outflow obstruction group, hypermotility group, hypomotility group, and normal motility group. Symptoms were evaluated using 3 questionnaires. Patient characteristics and symptoms for each EMD type were compared with those of the normal motility group. Results: Of the 394 patients, 193 (48.9%) were diagnosed with EMDs, including 71 with outflow obstruction, 15 with hypermotility, and 107 with hypomotility. The mean dysphagia score was significantly higher in each of the 3 EMD groups compared with those with normal motility. The mean acid reflux and dyspepsia scores were significantly lower in the outflow obstruction group (P < 0.05). The mean body mass index and median Brinkman index were significantly higher in the hypermotility group (P = 0.001 and P = 0.018, respectively), whereas the mean diarrhea and constipation scores were significantly lower in the hypomotility group (P < 0.05). Conclusions The results of our study indicate that different EMDs have distinct characteristics. Cigarette smoking and high body mass index were associated with esophageal hypermotility. Assessment of the dysphagia symptom scores may help identify patients with EMDs.

Background/Aims: Esophageal motility disorders (EMDs) contribute to the pathophysiology of gastroesophageal reflux disease. However, the causes of EMDs and their impact on gastroesophageal reflux disease-associated symptoms remain unknown. This study aims to elucidate clinical features associated with various types of EMDs in patients with heartburn symptoms. Methods: Of the 511 patients who underwent high-resolution manometry, 394 who were evaluated for heartburn symptoms were examined. Patients subjected to high-resolution manometry were classified into 4 groups: outflow obstruction group, hypermotility group, hypomotility group, and normal motility group. Symptoms were evaluated using 3 questionnaires. Patient characteristics and symptoms for each EMD type were compared with those of the normal motility group. Results: Of the 394 patients, 193 (48.9%) were diagnosed with EMDs, including 71 with outflow obstruction, 15 with hypermotility, and 107 with hypomotility. The mean dysphagia score was significantly higher in each of the 3 EMD groups compared with those with normal motility. The mean acid reflux and dyspepsia scores were significantly lower in the outflow obstruction group (P < 0.05). The mean body mass index and median Brinkman index were significantly higher in the hypermotility group (P = 0.001 and P = 0.018, respectively), whereas the mean diarrhea and constipation scores were significantly lower in the hypomotility group (P < 0.05). Conclusions The results of our study indicate that different EMDs have distinct characteristics. Cigarette smoking and high body mass index were associated with esophageal hypermotility. Assessment of the dysphagia symptom scores may help identify patients with EMDs.

A 52-year-old man underwent a medical examination, including abdominal computed tomography (CT). Abdominal CT revealed a common hepatic artery aneurysm (25 mm in diameter) ; a portion of the aneurysm depressed the pancreas. The gastroduodenal artery branched off the common hepatic artery aneurysm. We planned coil embolization for the common hepatic artery aneurysm. However, we could not avoid occluding the proper hepatic artery ; therefore, we performed abdominal aortic-proper hepatic artery bypass with coil embolization. The patient's postoperative course was uneventful.

We describe a 50-year-old man who was diagnosed with anomalous aortic origin of the right coronary artery (AAORCA) by coronary angiography and coronary computed tomography performed for chest pain on exertion. Exercise-loaded myocardial scintigraphy revealed inferior wall ischemia, and hence surgery was performed. Intraoperatively, the right coronary artery was seen to run in the aortic wall, and hence, right coronary ostioplasty (unroofing) was performed. Postoperatively, coronary computed tomography revealed that the right coronary artery originated from a normal position, and exercise-loaded myocardial scintigraphy indicated no ischemia.