We report a case of redo mitral valve replacement (MVR) for a Björk-Shiley Delrin valve implanted 47 years previously. A 71-year-old man initially underwent MVR for mitral regurgitation at our hospital at the age of 16 years. Following the operation, follow-up examinations were performed at the outpatient clinic and annual transthoracic echocardiogram findings showed only mild mitral regurgitation, with no adverse events noted. However, a transthoracic echocardiogram examination performed 45 years after the operation revealed mild to moderate mitral regurgitation, while dyspnea with exertion was also noted at that time. As part of a more detailed examination, transesophageal echocardiogram results showed moderate transvalvular leakage. Redo MVR was subsequently performed under the diagnosis of prosthetic valve dysfunction. Analysis of the explanted prosthetic valve revealed wear of the Delrin disk, and widening of the gap between the disk and strut, which were presumed to be the cause of transvalvular leakage. A half century has passed since introduction of the Björk-Shiley valve and the present is a rare case of valve malfunction. Presented here are related details, along with a review of existing literature and results of Björk-Shiley valve use at our hospital.

Objective : The mainstream strategy for blunt traumatic thoracic aortic injuries (BTAI) has been shifting from conventional open repair (OR) to thoracic endovascular aortic repair (TEVAR). Accordingly, we reviewed the short- and mid-term outcomes following surgical procedures of BTAI, comparing OR with TEVAR. Methods : We retrospectively collected data of consecutive cases of BTAI in a single institution from March 2001 to August 2019. Results : Eighteen cases were identified. Of these, 7 patients (38.9%, mean age 62.0±15.2 years) were treated with OR and 11 (61.1%, mean age 61.8±21.3 years) were treated with TEVAR. There was significant reduction in the mean operative duration (OR 444±145 vs TEVAR 65±14 min ; p＜0.001), the mean intraoperative blood loss (OR 2,787±1,578 vs TEVAR 210±376 ml ; p＜0.001), the volume of blood transfusions (OR 5,042±2,219 vs TEVAR 929±751 ml ; p＜0.001), and the mean dose of heparin infusion (OR 20.3±4.1 vs TEVAR 7.9±8.5 ml ; p＜0.01). Postoperative 30-day mortality of OR and TEVAR were 28.6 and 0% (p＝0.14), respectively. There was no endoleak, 1 case of paraparesis, and 1 case of bilateral cerebellar infarction in the TEVAR group. There was no significant difference in the length of stay in the intensive care unit, the duration of hospital stay, the rate of home discharge, or the mid-term mortality and re-intervention rate (average follow-up period of 42.0±56.9 months). Conclusions : Compared with OR, TEVAR took less operative time with less bleeding, and required less blood transfusions and heparin. The short- and mid-term outcomes following TEVAR for BTAI was favorable and TEVAR appears to be applicable as a first-line treatment for BTAI.

The patient in this case was a boy aged 2 years and 9 months. The patient was transferred to our hospital with ductal shock, and bilateral pulmonary artery banding was performed on the 9th day after the diagnosis of interruption of the aortic arch, ventricular septal defect, subaortic stenosis, and bicuspid aortic valve. Left ventricular outflow tract stenosis due to aortic annulus diameter and subaortic stenosis after repair was suspected. Damus-Kaye-Stansel (DKS) anastomosis, extended aortic arch anastomosis, and a right modified Blalock-Taussig operation were performed. Preoperative examination of the intracardiac repair showed growth of the aortic annulus and confirmed that biventricular repair was possible after DKS take-down. The patient's native aortic and pulmonary valves were preserved, and an intracardiac repair was performed without using an extracardiac conduit. The postoperative course was uneventful, and the patient is currently in a good condition at the age of 6 years. Three and a half years after surgical intervention, echocardiography and cardiac catheterization showed improvement of subaortic stenosis and enlargement of the aortic annulus. Our findings indicate that the most appropriate surgical procedure can be selected by detailed examination of the preoperative condition at each stage of the staged operation.

BACKGROUND/AIMS: Although studies using conventional animal models have shown that specific stressors cause irritable bowel syndrome (IBS), it is unclear whether depression itself causes IBS. Our aim was to establish a rat model to determine if depression itself promotes the onset of IBS and to elucidate the role of gut microbiota in brain-gut axis pathogenesis during coincident depression and IBS. METHODS: Rat models of depression were induced using our shuttle box method of learned helplessness. Visceral hypersensitivity was evaluated by colorectal distension (CRD) to diagnose IBS. Gut microbiota compositions were analyzed using high-throughput sequencing. In the subanalysis of rats without depression-like symptoms, rats with posttraumatic stress disorder (PTSD) were also examined. RESULTS: The threshold value of CRD in depressed rats was significantly lower than that in control rats. Microbial community analysis of cecal microbiota showed that the relative abundance of Clostridiales incertae sedis, the most prevalent microbe, was significantly lower in depressed rats than in control rats. The distribution pattern of the microbiota clearly differed between depressed rats and control rats. Neither visceral hypersensitivity nor the composition of gut microbiota was altered in rats with PTSD-like phenotypes. CONCLUSIONS: Our rat model of depression is useful for clarifying the effect of depression on IBS and suggests that depression itself, rather than specific stressors, promotes the onset of IBS. Further, we provided evidence that various psychiatric diseases, viz., depression and PTSD, are associated with unique gut microbiota profiles, which could differentially affect the onset and progression of coincident IBS.
Animals ; Clostridiales ; Depression ; Dysbiosis ; Gastrointestinal Microbiome ; Helplessness, Learned ; Hypersensitivity ; Irritable Bowel Syndrome ; Methods ; Microbiota ; Models, Animal ; Phenotype ; Rats ; Stress Disorders, Post-Traumatic

Multiple system atrophy (MSA) is an adult-onset, progressive neurodegenerative disorder. Patients with MSA show various phenotypes during the course of their illness, including parkinsonism, cerebellar ataxia, autonomic failure, and pyramidal signs. Patients with MSA sometimes present with isolated autonomic failure or motor symptoms/signs. The median duration from onset to the concomitant appearance of motor and autonomic symptoms is approximately 2 years but can range up to 14 years. As the presence of both motor and autonomic symptoms is essential for the current diagnostic criteria, early diagnosis is difficult when patients present with isolated autonomic failure or motor symptoms/signs. In contrast, patients with MSA may show severe autonomic failure and die before the presentation of motor symptoms/signs, which are currently required for the diagnosis of MSA. Recent studies have also revealed that patients with MSA may show nonsupporting features of MSA such as dementia, hallucinations, and vertical gaze palsy. To establish early diagnostic criteria and clinically definitive categorization for the successful development of disease-modifying therapy or symptomatic interventions for MSA, research should focus on the isolated phase and atypical symptoms to develop specific clinical, imaging, and fluid biomarkers that satisfy the requirements for objectivity, for semi- or quantitative measurements, and for uncomplicated, worldwide availability. Several novel techniques, such as automated compartmentalization of the brain into multiple parcels for the quantification of gray and white matter volumes on an individual basis and the visualization of α-synuclein and other candidate serum and cerebrospinal fluid biomarkers, may be promising for the early and clinically definitive diagnosis of MSA.
Biomarkers ; Brain ; Cerebellar Ataxia ; Cerebrospinal Fluid ; Dementia ; Diagnosis ; Early Diagnosis ; Hallucinations ; Humans ; Multiple System Atrophy ; Neurodegenerative Diseases ; Paralysis ; Parkinsonian Disorders ; Phenotype ; White Matter

Thirty two years-old man with arthralgia in both hands was given with non-steroid anti-inflammatory drug and followed. The symptoms persisted, and hematuria and signs of infection were getting apparent. The patient was referred to our hospital with increasing dyspnea. The patient presented acute heart failure, acute renal insufficiency and respiratory failure. Echocardiography revealed vegetation and regurgitation in the aortic and mitral valve. Blood culture demonstrated α-Streptococcus. CT revealed enlargement of the aortic root. The patient was diagnosed with infectious endocarditis, and referred for surgery. At surgery, the aortic valve and mitral valve were severely destroyed. Aortic root and mitral valve replacement were performed. Pathological findings demonstrated valve destruction as a result of endocarditis due to active rheumatic fever. Clumps of bacteria were not noted around the valves. This is a rare adult case with valve destruction by acute rheumatic fever.

Although aortic annular abscess and rupture of the sinus of Valsalva are known as complications of infective endocarditis, few cases in children have been reported. We report a surgical case of a 6-year-old girl with active infective endocarditis complicated with an annular abscess and pseudoaneurysm of the sinus of Valsalva. The patient presented progressive symptoms of heart failure and a subsequent echocardiogram demonstrated severe aortic regurgitation. A computed tomography indicated pseudoaneurysm of sinus of Valsalva and an emergency operation was performed. At operation, a bicuspid aortic valve with vegetation was noted. The annular abscess caused a large tissue defect of the left coronary sinus of Valsalva and formed a pseudoaneurysm. The infected lesion was resected completely. The defective aortic annulus and sinus of Valsalva were repaired with a bovine pericardial patch and aortic valve was replaced with a mechanical valve. The postoperative course was uneventful and the patient was discharged after adequate antibiotic treatment.

Objective: Our previous studies suggested that hot spring aquatic exercise may immediately improve the balance ability. As the long-term effects of such repeated exercise have not yet been examined, this present study aims to analyze them, focusing on the balance-related physical indexes. Methods: A total of 12 patients (the number of cerebrovascular disease patients: 5; the number of orthopedic disease patients: 7; mean age: 71.9±13.1; FIM: 117±7.5; and FBS score: 46.4±6.7), who had been treated with hot spring aquatic exercise therapy in our hospital were studied. Each patient showed decreased balance ability due to paralysis, sensory disturbance, or fracture. The measurement indexes were the ability to bend forward while sitting with their legs straight, Functional Balance Scale (FBS), Functional Reach Test (FRT) and Timed Up and Go (TUG) scores, sensory function was measured by the instrument (Semmes-Weinstein Monofilaments), and skin stiffness. Those were measured immediately, 10, 20, and 30 days after the initiation of the intervention.   Furthermore, indexes of eight patients out of those were measured 60 days after the initiation. Each exercise session consisted of walking forward and backward, hip abduction, flexion, and extension, lunge, and squat, which lasted approximately 15 minutes. The loading level was set at a pulse of 77±11.2 ≧ 84±13.5/minute, with a perceived exertion rate (modified Borg Scale) of 0.7±1.0 ≧ 2.4±2.3. Results: The ability to bend forward while sitting with their legs straight, TUG, FBS and sensory function, scores have improved significantly. Any significant improvements were not observed on FRT and skin stiffness. Discussion: The improvement of the sensory function was observed in patients with cerebrovascular disease. This would be because these therapies have the effect on the improvement of higher neuronal function. It is assumed that training efficiency in itself was improved, as the buoyancy and hydrostatic pressure assisted the patients to keep balance.   This exercise showed more effectiveness on the complicated balance indexes. On evaluation of each balance index, the TUG scores significantly improved significantly, while the FRT scores did not show any effects. As the balance-related indexes started to show improvements 30 days after the initiation, it should be recommended to continue this exercise for 30 days or more. Furthermore, in those who had not reached the maximum FBS score 30 days after the initiation, the improvement in scores was observed after 60 days. Further studies will be necessary to analyze these physical indexes, which showed improvements so that more effective exercises for each patient can be programmed taking the relevant balance-related physical indexes into account.

A 39-year-old woman, who had undergone aortic valve replacement with a Carpentier-Edwards pericardial bioprosthesis 16 years previously, was admitted to our hospital with a diagnosis of acute heart failure due to acute aortic regurgitation. An emergency operation was undertaken with the patient in a state of shock due to sudden cardiac arrest. The ascending aorta was cross clamped, and cardiac arrest was induced, and aortotomy was done. One of the leaflets of the CEP was entirely collapsed and dislocated to the LV side, which caused acute aortic regurgitation. Although there was no evidence of endocarditis, slight calcification and small perforation of the leaflet of the valve was observed. Aortic valve replacement was performed with a mechanical heart valve but it was impossible to wean from ECC, and therefore we additionally performed mitral valve annuloplasty with a prosthetic ring for moderate mitral regurgitation. After 4 h cardiopulmonary assistance, ECC was successfully withdrawn. She was discharged in a good condition an post operative day 29th.

Papillary muscle rupture is one of the common complications of acute myocardial infarction. We report a case of 77-years-old man with an acute posterior papillary muscle rupture without obvious coronary artery disease. The patient presented with cardiogenic shock and pulmonary edema. Emergency coronary angiogram showed no obstruction in coronary arteries. An echocardiogram and right heart catheterization data suggested acute mitral regurgitation caused by ruptured posterior papillary muscle. Percutaneous cardiopulmonary support was induced because of his unstable hemodynamics, and then emergency mitral valve replacement was performed. Intraoperative findings suggested some ischemic changes in the posterior papillary muscle. Pathologically, both old and new ischemic lesion presented in the same papillary muscle. Moreover, severe thickening of a small vessel wall was noted. This case presented one of the possible mechanisms of so-called idiopathic papillary muscle rupture.