Background/Aims: Tofacitinib and upadacitinib are small-molecule compounds that inhibit the Janus kinase pathway for the treatment of refractory ulcerative colitis. Only a few reports have compared the efficacy and safety of these 2 drugs in real-world practice. We aimed to show our real-world evidence of these drugs and compare the efficacy and safety profiles in the treatment of ulcerative colitis. Methods: This study is a single-center retrospective analysis. Patients treated with tofacitinib or upadacitinib at our hospital between June 2018 and January 2024 who were monitored for 24 weeks were included. The primary outcome was steroid-free clinical remission at 24 weeks. Secondary outcomes were response and remission rates at each time point, time series changes in partial Mayo scores and laboratory results, treatment survival at 24 weeks, and the incidence of adverse events. Results: A total of 68 patients treated with tofacitinib and 34 patients treated with upadacitinib were included. Steroid-free clinical remission rate at 24 weeks was significantly higher in upadacitinib-treated patients than in tofacitinibtreated patients (64.7% vs. 38.2%). The response rates in upadacitinib-treated patients exceeded 60% after 8 weeks of treatment through to 24 weeks, and the rates were higher than those in tofacitinib-treated patients. The incidences of adverse events were 79.4% in upadacitinib-treated patients and 38.2% in tofacitinib-treated patients. The most common adverse event was acne for upadacitinib. Conclusions Upadacitinib was more effective than tofacitinib in inducing remission in ulcerative colitis patients. The incidence of adverse events was significantly higher with upadacitinib than tofacitinib.

Background/Aims: Endoscopic activity confirmed by enteroscopy is associated with poor clinical outcome in Crohn’s disease (CD). We investigated which of the existing biomarkers best reflects endoscopic activity in CD patients including the small bowel, and whether their combined use can improve accuracy. Methods: One hundred and four consecutive patients with ileal and ileocolonic type CD who underwent balloon-assisted enteroscopy (BAE) from October 2021 to August 2022 were enrolled, with clinical and laboratory data prospectively collected and analyzed. Results: Hemoglobin, platelet count, C-reactive protein, leucine-rich alpha-2 glycoprotein (LRG), fecal calprotectin, and fecal hemoglobin all showed significant difference in those with ulcers found on BAE. LRG and fecal calprotectin showed the highest areas under the curve (0.841 and 0.853) for detecting ulcers. LRG showed a sensitivity of 78% and specificity of 80% at a cutoff value of 13 μg/mL, whereas fecal calprotectin showed a sensitivity of 91% and specificity of 67% at a cutoff value of 151 μg/g. Dual positivity for LRG and fecal calprotectin, as well as LRG and fecal hemoglobin, both predicted ulcers with an improved specificity of 92% and 100%. A positive LRG or fecal calprotectin/hemoglobin showed an improved sensitivity of 96% and 91%. Positivity for LRG and either of the fecal biomarkers was associated with increased risk of hospitalization, surgery, and relapse. Conclusions The biomarkers LRG, fecal calprotectin, and fecal hemoglobin can serve as noninvasive and accurate tools for assessing activity in CD patients confirmed by BAE, especially when used in combination.

Background/Aims: The efficacy and safety of tofacitinib for the treatment of refractory ulcerative colitis (UC) has been demonstrated in clinical trials. Although, a series of reports with real-world evidence of its short-term efficacy and safety profiles have already been published, reports of long-term real-world data have been limited. We aimed to show our 3-year evidence on the clinical use of tofacitinib for the treatment of UC, focusing on its efficacy and safety profiles. Methods: A retrospective observational study was conducted on patients who started tofacitinib for active refractory UC at our hospital. The primary outcome was the retention rate until 156 weeks after initiating tofacitinib. The secondary outcomes were short-term efficacy at 4, 8, and 12 weeks; long-term efficacy at 52, 104, and 156 weeks; prognostic factors related to the cumulative retention rate; loss of response; and safety profile, including adverse events. Results: Forty-six patients who were able to be monitored for up to 156 weeks after tofacitinib initiation, were enrolled in this study. Continuation of tofacitinib was possible until 156 weeks in 54.3%, with > 50% response rates and > 40% remission rates. Among patients in whom response or remission was achieved and tofacitinib was deescalated after 8 weeks of induction treatment, 54.3% experienced relapse but were successfully rescued by and retained on reinduction treatment, except for 1 patient. No serious AEs were observed in the study. Conclusions Tofacitinib is effective and safe as long-term treatment in a refractory cohort of UC patients in real-world clinical practice.

A 41-year-old man had undergone mitral valve replacement (On-X 27/29 mm) and tricuspid valve replacement (TVR) (On-X 31/33 mm) for infectious endocarditis of the mitral valve and severe tricuspid regurgitation 6 years ago. Postoperative echocardiography showed aortic regurgitation and perivalvular leakage of the prosthetic mitral valve and left ventricular (LV) septal perforation. He therefore underwent aortic valve replacement (On-X 25 mm), patch closure of a leak around the prosthetic mitral valve, direct closure of the LV septal perforation, and re-TVR (On-X 31/33 mm). After discharge, he was placed on anticoagulant therapy with warfarin (international normalized ratio of prothrombin time target : 2.0-2.5). Transthoracic echocardiography three and -a half years after the operation revealed an increased mean tricuspid valvular pressure gradient (14 mmHg) compared with that seen on an echocardiograph of previous year. Cine-fluoroscopy showed almost no movement of the leaflets of the mechanical tricuspid valve. Tricuspid valve thrombosis or pannus formation was suspected. He was placed on thrombolytic therapy using tissue plasminogen activator (monteplase 1.6 million units). Five days later, cine-fluoroscopy showed movement of the mechanical tricuspid valve leaflets, and echocardiography revealed recovery of the mean tricuspid valve pressure gradient (4 mmHg). Valvular thrombosis was diagnosed as the cause of the non-moving valve. Hemorrhagic and embolic complications were not observed. Thrombolytic therapy was extremely useful.

A 72-year-old man, in whom hypertrophic cardiomyopathy (HCM) had been treated with medication for 4 years, complained of general fatigue and mild dyspnea on effort. Transthoracic and transesophageal echocardiography revealed diffuse left ventricular (LV) hypertrophy and LV obstruction from the mid-portion to the outflow tract with a peak pressure gradient of 94 mmHg. Additionally, anterior displacement of the abnormal, hypertrophied anterior papillary muscle (PM) and restricted motion of the anterior mitral leaflet, caused by the shortened chordae arising from the abnormal PM, were found. Furthermore, during the systolic phase, the abnormal, hypertrophied anterior PM was shifted to the septal side, causing LV obstruction with systolic anterior motion of the mitral leaflet. The diagnosis was HCM with LV obstruction due to abnormal PM. Mitral valve replacement (MVR) using a mechanical valve and excision of the abnormal PM was performed. His postoperative course was uneventful, and he was discharged on the 14th postoperative day. Postoperative echocardiography revealed no residual obstruction and no pressure gradient in the LV, indicating that complete release of the LV obstruction had been accomplished. In cases of HCM with LV obstruction due to an abnormal mitral subvalvular apparatus, transaortic septal myectomy may not always be an effective procedure. Therefore, we propose that MVR with excision of the PM should be considered one of the useful surgical procedures for such cases.

A 62-year-old man with a history of insulin-dependent diabetes mellitus was admitted to our hospital because of a high-grade fever and general fatigue. Laboratory data showed evidence of inflammation and Streptococcus pneumoniae was identified in the blood cultures. Transthoracic echocardiography revealed vegetations on the right coronary cusp of the aortic valve and septal leaflet of the tricuspid valve, and an aorto-right ventricular fistula secondary to abscess formation in the aortic annulus. We diagnosed active infective endocarditis with an aorto-cavity fistula and performed an emergency operation. The infected tissue was curetted as much as possible and the fistulous openings in the right ventricle and aortic root were closed using bovine pericardial patches. We subsequently performed aortic annular reconstruction and aortic full-root replacement using a Freestyle^® stentless valve. Although a permanent pacemaker was implanted to treat a complete atrioventricular block, the postoperative course was uneventful and the C-reactive protein level normalized. He was discharged on the 46th postoperative day. Postoperative echocardiography revealed no signs of valve dysfunction, recurrent endocarditis, or residual abscess cavity and shunt. Infective endocarditis with abscess formation complicated by a fistula formation between the cardiac chambers is rare, and surgical treatment for this is challenging. In such cases, both radical debridement of the infected tissue and precise closure of the fistulous tract are essential.

Nonocclusive mesenteric ischemia (NOMI) after cardiac surgery is a rare and fatal complication. Although there are a few reports of successful treatment of NOMI, progress after treatment is not known. This case report describes the postoperative course of a 79-year-old male patient who underwent successful treatment of NOMI after aortic valve replacement (AVR). Plain abdominal computed tomography revealed gas in the small intestinal wall 14 days after AVR. Emergency massive small bowel resection was performed because wide and discontinuous necrotic changes of the small intestine were confirmed. Although the patient temporarily returned to normal life after discharge, sepsis due to urinary tract infection or acute cholecystitis and central venous route infection occurred repeatedly. The patient was intermittently admitted for a total of 14 of 25 months after the first discharge. The patient died of sepsis due to Candida infection and liver failure 52 months after AVR. Even if treatment for NOMI is successful, there is an unfavorable prognosis in terms of immunity and nutrition for short bowel syndrome. Because there are no symptoms or laboratory data specific to NOMI, it is considered important to immediately and adequately diagnose and treat NOMI without overlooking abnormalities after cardiac surgery.

In 1984, a 67-year-old man had aortic valve replacement surgery for aortic regurgitation; he returned with chest pain on May 15, 2003. Emergency coronary angiography was performed because electrocardiogram revealed ST segment depression in leads V₄ to V₆. However, coronary angiography, echocardiogram and chest computed tomography finding were normal. Therefore the patient was discharged the following day. However, he was re-admitted for chest pain, followed by loss of consciousness 4 days after his initial release. Echocardiogram and chest computed tomography revealed perforation in the lateral wall of his left ventricle (LV) and a “blow-out” type rupture was diagnosed. The patient fell into cardiogenetic shock in the emergency room, and emergency left ventricular free wall rupture (LVFWR) surgical repair was performed under percutaneous cardiopulmonary support (PCPS). A round perforation measuring about 10mm in diameter was observed in the lateral LV wall along the course of LCx # 12. The perforation was closed using Teflon strip reinforced mattress sutures. The hemostasis was reinforced with fibrin glue sheet (TachoComb) and polyglygolic acid surgical mesh (Dexon Mesh), with fibrin glue extensively applied. He was discharged on July 17, 2003 without major complications. In this case, the precise cause that led to LVFWR was unknown. Emergency PCPS insertion enabled the LVFWR surgical repair and extensive adhesion due to the previous AVR prevented the massive bleeding to pericardial cavity and the catastrophic hemodynamic deterioration: both factors positively contributed to patient recovery.

A 64-year-old man was transferred to our hospital because of acute heart failure associated with myocardial infarction. Echocardiography revealed severe mitral regurgitation due to total rupture of the posterior papillary muscle. Following the diagnosis of papillary muscle rupture, intraaortic balloon pumping support was started, and surgery was performed without coronary angiography because of cardiogenic shock and renal dysfunction. The posterior papillary muscle was completely ruptured, and the anterior leaflet of the mitral valve was severely prolapsed. Without resecting the posterior leaflet, mitral valve replacement was successfully performed using a St. Jude Medical^® prosthetic valve. The postoperative course was uneventful except for ventricular tachyarrhythmia which occurred during the acute phase postoperatively. Postoperative coronary angiography demonstrated no significant coronary arterial stenosis. In a patient with cardiogenic shock due to papillary muscle rupture, immediate surgical intervention is recommended as soon as the diagnosis has been established by echocardiography.