A 23-year-old woman with mitral valve infective endocarditis complicated by embolism of the right common iliac artery underwent transfemoral embolectomy by a Fogarty catheter and mitral valve replacement. She developed occlusion of the right internal iliac artery, that was revealed by computed tomography on the 9th postoperative day. The occlusion was considered to result from migration of a part of the emboli from the right common iliac artery into the right internal iliac artery during the procedure of embolectomy. On the 16th postoperative day, she underwent repeat mitral valve replacement because of perivalvular leakage. Furthermore, after 2 weeks from the diagnosis of embolism of the right internal iliac artery, the embolic site showed aneurysmal formation finally requiring aneurysmectomy. Her recovery was uneventful. Our case is considered to be rare in that serial observations on computed tomography indicated the development of mycotic aneurysm at the site of septic embolism. In addition, care must be taken to prevent migration of emboli into branched arteries during the procedure of embolectomy for peripheral arterial septic embolism caused by infective endocarditis.

We report two cases of extended sandwich patch technique through right ventriculotomy for ventricular septal perforation (VSP). One was an 82-year-old woman. Preoperative coronary angiography showed occlusion of the left anterior descending artery proximal to the first major septal branch. Operative inspection revealed relatively extensive infarction of the anterior wall, a part of which had the appearance of free wall rupture. In the other case of an 85-year-old woman, the culprit lesion was occlusion of the left anterior descending artery distal to several septal branches and to the first diagonal branch. Despite their old age and emergency surgery in cardiogenic shock status, their postoperative recovery was uneventful. In the former case, however, echocardiography at the early postoperative phase revealed significant expansion and thinning of the infarcted anterior wall. Furthermore, serial observations showed deterioration of the left ventricular systolic function and mitral regurgitation due to leaflet tethering. In addition to secure VSP closure by transmural stitches, extended sandwich patch technique can offer geometric and functional preservation of postinfarction left ventricle. Although this can eliminate the risk of postoperative low output syndrome even if anterior infarction is extensive, late follow-up will be required because this technique can also allow postinfarction left ventricular remodeling.

A 61 year-old man was admitted with fever and chest discomfort. He had undergone aortic root replacement for annuloaortic ectasia at age 57. Computed tomography showed a pseudoaneurysm and an abscess formation around the aortic root. Prosthetic valve endocarditis was diagnosed and the underwent repeat aortic root replacement. After debridement and irrigation of the abscess cavity, the left ventricular outflow tract was reconstructed with an equine pericardium, which was rolled to form a conduit. The pericardial conduit was securely sutured to the healthy left ventricular wall and the mitral annulus. A 25 mm-Freestyle valve was then sutured to the distal end of the conduit. The previous prosthetic vascular graft was removed and Completely replaced with a new prosthesis. This method provided secure fixation of a new prosthetic valved conduit to the normal left ventricular tissue with an excellent operative visual field.

The development of clinically applicable scaffolds is important for the application of cell transplantation in various human diseases. The aims of this study are to evaluate fibrin glue in a novel protein replacement therapy using proliferative adipocytes and to develop a mouse model system to monitor the delivery of the transgene product into the blood and the fate of the transduced cells after transplantation. Proliferative adipocytes from mouse adipose tissue were transduced by a retroviral vector harboring the human lecithin-cholesterol acyltransferase (lcat) gene, and were subcutaneously transplanted into mice combined with fibrin glue. The lcat gene transduction efficiency and the subsequent secretion of the product in mouse adipocytes were enhanced using a protamine concentration of 500 microg/ml. Adipogenesis induction did not significantly affect the lcat gene-transduced cell survival after transplantation. Immunohistochemistry showed the ectopic enzyme production to persist for 28 days in the subcutaneously transplanted gene-transduced adipocytes. The increased viability of transplanted cells with fibrin glue was accompanied with the decrease in apoptotic cell death. The immunodetectable serum LCAT levels in mice implanted with the fibrin glue were comparable with those observed in mice implanted with Matrigel, indicating that the transplanted lcat gene-transduced adipocytes survived and functioned in the transplanted spaces with fibrin glue as well as with Matrigel for 28 days. Thus, this in vivo system using fibrin is expected to serve as a good model to further improve the transplanted cell/scaffold conditions for the stable and durable cell-based replacement of defective proteins in patients with LCAT deficiency.
Adipocytes/*cytology/transplantation ; Animals ; Blotting, Western ; Cell Differentiation ; Cell Survival/drug effects ; Cells, Cultured ; Collagen/metabolism ; Drug Combinations ; Drug Delivery Systems ; Fibrin Tissue Adhesive/*administration & dosage ; Genetic Vectors/administration & dosage ; Humans ; Laminin/metabolism ; Male ; Mice ; Mice, Inbred C57BL ; Mice, Nude ; Phosphatidylcholine-Sterol O-Acyltransferase/*genetics/*metabolism ; Proteoglycans/metabolism ; RNA, Messenger/genetics ; Reverse Transcriptase Polymerase Chain Reaction ; *Tissue Engineering

Aggressive anticoagulation therapy is necessary when Toyobo-LVAS is used for long-term treatment of severe heart failure. However, it is necessary to regulate it carefully if there is a hemorrhagic complication due to thromboembolism, but repeated blood testing is painful. We compared simple measurement with the CoaguChek XS^® with the conventional blood testing method. The correlation coefficient was 0.916, and the regression line was Y=0.8027X+0.3399. In addition, drawing blood using the CoaguChek XS^® was very effective in the reported pain reduction in patients.

An 83-year-old woman underwent stent graft endovascular repair using a Medtronic TALENT device for a saccular aortic aneurysm in the distal arch. The landing zone which targeted the proximal side was directly distal to the orifice of the left common carotid artery (Z2), and the stent graft was placed at the targeted position. However, a decline in the right radial arterial pressure was observed immediately following this, and a retrograde dissected ascending aorta was observed on a transesophageal echocardiogram. The endovascular surgery was immediately converted to open surgery, and an intimal tear to the lesser curvature of the arch, caused by a bare spring (bare stent) of the proximal stent graft, was observed. Total arch replacement was performed by means of the concomitant use of the placed stent graft. Sometimes a TALENT stent graft exhibits specific movements (e.g. a misaligned opening) on its initial deployment. It is therefore believed that special attention is necessary when placing it in the aortic arch.

We conducted a clinical study on a newly developed large diameter vascular graft (Triplex^®, Terumo Corporation, Tokyo, Japan) with a non-biodegradable material used as sealing material, to evaluate its effectiveness and safety. Triplex^® grafts were implanted in 170 patients with either aneurysmal or occlusive arterial disease in either the thoracic artery, abdominal artery or iliac arteries, between October 2001 and March 2003. The patients consisted of 141 men and 29 women with an average age of 69.0±10.0 years old (mean±SD). In 82 patients, Triplex^® was implanted for the thoracic artery area, in 88, for the abdominal artery area. The cumulative graft patency rate 12 months after implantation was 100.0% in each area, there was no any abnormality such as occlusion or rupture from the trunk of Triplex^®. The distension ratio, which is the index of the dilatation resistance, was 1.03±0.06 as a whole (n=139), 1.03±0.06 in the thoracic artery area (n=73), 1.03±0.06 in the abdominal artery area (n=66). In other words the dilatation of Triplex^® was hardly observed. As manipulability during the operation, the following characteristics were evaluated; anastomosis, resistance to fraying, hemorrhage, conformability with the host vessel. Triplex^® was evaluated as “good” in 75% of all items accounted for 75% or more. A transitory rise thought to be due to the surgical stress immediately after the operation because of the change of temperature and laboratory findings (CRP, WBC) between implantation and discharge was observed, but then recovered to the normal levels of each patients at discharge and the re-elevation was not recognized. In 90 patients, 277 adverse events occurred. Although in 33 adverse events in 21 patients a causal relation with Triplex^® could not be excluded, most of them were already known events as complications which could occur after operation on the aorta. Therefore, it was confirmed that Triplex^® has certain advantages: 1) good manipulability, 2) good patency and dilatation resistance, 3) no inflammatory reaction related to Triplex^®, as a graft for the aorta.

Infra-renal abdominal aortic aneurysms were electively treated by bifurcated endovascular stent grafts (Power Web^TM system, Endologix Co., USA) at 5 Japanese centers. The stent grafting (SG) was applied for candidates nominated by the selection committee after informed consent was obtained according to the IRB in each center. The delivery success rate of 60 patients (53 males) was 96.7%. There were 2 patients with type I endoleaks, resulting in a technical success rate of 93.3%. The operation time of 193±55min and blood loss of 440±240g were significantly shorter and less, respectively in the SG group when compared with 303±88min and 1, 496±2, 025g in 97 patients (83 males) treated by conventional open surgery. Endoleaks were detected in 4 patients (type I: 3, type II: 1) by CT scan taken at the time of discharge or 1 month after SG procedure. Type I endoleak was observed in patients with short and severely angulated SG landing zones. Renal artery obstruction, and temporary buttock pain caused by internal iliac artery occlusion occurred, but there was no hospital death. In 56 patients excluding an SG-unrelated death and a dropout from surveillance, there was no secondary endoleak or marked adverse events at all except 1 SG limb occlusion during a 6-month follow up period. The aneurysm size shrank in 26 patients and remained unchanged in 30 patients. No aneurysm enlargement was observed. The Power Web^TM system is appropriate for minimally invasive surgery for abdominal aortic aneurysms. Long-term follow-up studies will follow.

There are rare reports of families with multiple members with aortic dissection in the absence of Marfan syndrome. We encountered four cases of aortic dissection in two families. The aortic dissection occurred in the mother and child of the first family and in sisters of the second family. All cases had systemic hypertension preoperatively and presented Stanford type A aortic dissection. All of them were operated successfully. None of them showed the characteristics of connective tissue disease affecting the skeletal, ocular, and cardiovascular system. However, many members of the two families had systemic hypertension and histopathological examination of the aorta showed cystic medial necrosis in all of the four cases. The present study suggests that the familial aortic dissection may be caused by weakness of the aortic wall related to heredity and systemic hypertension.

Shprintzen-Goldberg syndrome (SGS) is a rare disorder with many characteristics of generalized connective tissue dysplasia. SGS is characterized by Marfanoid habitus with craniosynostosis and mental retardation. Patients with SGS have cardiovascular disorders similar to Marfan syndrome (MFS) and those disorders seem to play an important role in the prognosis of SGS. To our knowledge, only 19 patients with SGS have been reported, and 7 of them had cardiovascular disorders. The major cardiovascular disorders of SGS are aortic root dilatation and mitral valve prolapse. We reported the first case of SGS successfully treated surgically for cardiovascular disorders. Since then, we performed another operation in a patient with SGS. In this paper, we report our surgical results in patients with SGS.