Background: Type 1 diabetes mellitus induced by immune-checkpoint inhibitors (ICI-T1DM) is a rare critical entity. However, the etiology of ICI-T1DM remains unclear. Methods: In order to elucidate risk factors for ICI-T1DM, we evaluated the clinical course and immunological status of patients with ICI-T1DM who had been diagnosed during 2016 to 2021. Results: Seven of 871 (0.8%, six men and one woman) patients developed ICI-T1DM. We revealed that the allele frequencies of human leukocyte antigen (HLA)-DPA1*02:02 and DPB1*05:01 were significantly higher in the patients with ICI-T1DM In comparison to the controls who received ICI (11/14 vs. 10/26, P=0.022; 11/14 vs. 7/26, P=0.0027, respectively). HLA-DRB1*04:05, which has been found to be a T1DM susceptibility allele in Asians, was also observed as a high-risk allele for ICI-T1DM. The significance of the HLA-DPB1*05:01 and DRB1*04:05 alleles was confirmed by an analysis of four additional patients. The absolute/relative neutrophil count, neutrophils-lymphocyte ratio, and neutrophil-eosinophil ratio increased, and the absolute lymphocyte count and absolute/relative eosinophil count decreased at the onset as compared with 6 weeks before. In two patients, alterations in cytokines and chemokines were found at the onset. Conclusion Novel high-risk HLA alleles and haplotypes were identified in ICI-T1DM, and peripheral blood factors may be utilized as biomarkers.

Ten patients, aged 3 to 43 years, with the tetralogy of Fallot underwent in situ pulmonary valve replacement (PVR) 13 times. The implanted valves were a St. Jude Medical prosthesis (3 times) and a bioprosthetic valve (10 times). In 5 patients PVR was performed at the time of radical repair and in the remaining 5 patients PVR was performed after radical repair. Three patients underwent re-PVR at 6 to 13 years after the first PVR. There was one operative death in re-PVR 14 years after the first PVR and one patient died from congestive heart failure 4 years after PVR. In the patients with the tetralogy of Fallot, the rate of PVR in those who had undergone open Brock's operation were significantly higher than that of the patients without open Brock's operation (p<0.05). Actuarial survival rates at 5 years and 10 years were 88.9% and 88.9%, respectively. Rates of freedom from reoperation at 5 years and 10 years were 88.9% and 59.3%, respectively. Although the early operative results are satisfactory, re-PVR is mandatory in the future. Thus the indications of PVR should be considered carefully.

A 64-year-old woman with dyspnea on exertion was referred to our hospital. CT revealed type B aortic dissection with 7cm of aneurysm including a thrombus in the false lumen at the distal aortic arch. Four intimal tears at the distal aortic arch were closed directly during hypothermic circulatory arrest, and the descending thoracic aorta was tailored without a prosthetic graft after fixation of the dissecting adventitia to the intima at the distal portion of the false lumen. The postoperative course was uneventful and this patient was discharged on the 22nd postoperative day. Three years after surgery, the postoperative CT revealed no evidence of dilatation of the descending thoracic aorta as far as the abdominal aorta although the dissection of thoracoabdominal aorta remained. This technique is effective as an surgical option for chronic type B aortic dissection to minimize operative stress and complications.

Thrombomodulin is an endothelial cell membrane protein that is released into the blood in soluble forms in response to endothelial damage. We evaluated thrombomodulin in blood samples taken from the femoral vein before, during and after elective surgery for abdominal aortic aneurysm in 9 patients. Thrombomodulin was measured using an ETA assay. Thrombomodulin decreased significantly just before aortic declamp from before surgery (p<0.001), and remained unchanged just after and 1 hour after aortic declamp. Three hours after aortic declamp, thrombomodulin increased significantly from 1 hour after aortic declamp (p<0.01), peaked at 6 hours after aortic declamp and then decreased. These data suggest that thrombomodulin did not increase significantly during surgery for abdominal aortic aneurysm.

We present a rare case of acute type A dissection which developed compression of the true lumen after starting cardiopulmonary bypass (CPB) with femoral arterial return. In this case, the entry was located in the proximal descending thoracic aorta, and the dissection expanded up to the ascending aorta in a retrograde direction. After starting CPB, the false lumen suddenly enlarged and the true lumen was compressed. We observed those changes by intraoperative transesophageal echocardiography, so the perfusion was stopped immediately. A long arterial cannula (Wessex) was inserted from the left ventricular apex with the tip of the cannula remaining in the true lumen of the ascending aorta, and antegrade perfusion was restarted. After that we could maintain adequate extracorporeal perfusion and the replacement of the total aortic arch was completed uneventfully.

We encountered an unusual disruption of an expanded polytetrafluoroethylene (EPTFE) axillofemoral bypass graft apart from that anastomoses. We suspected the possible robe of the physical effects of body movement provoking the disruption of the axillofemoral bypass graft and therefore examined the physical effect of body movement on the axillary-to-femoral artery graft in 15 healthy men. At the lower part of the graft, the physical effect was significantly stronger. The disruption of this axillary-to-femoral artery graft was associated with the physical effect of body movement.

The purpose of this study was to determine the effect of intraoperative autologous blood salvage during elective abdominal aortic aneurysm repair with Cell Saver 4 (Heamonetics Inc.). Fifty patients prospectively received intraoperative autologous transfusion (Group CS; n=50, 1991-94) and 25 received no intraoperative autologous transfusion (Group NCS; n=25, 1983-91). Only 7 patients in Group NCS received no homologous blood (28%), while 43 in Group CS received autologous blood transfusion (86%). There was no difference between the groups with respect to postoperative platelets counts or serum concentrations of total protein, albumin, BUN and LDH. We conclude that the use of the Cell Saver 4 reduces perioperative homologous blood during elective aortic aneurysm repair.

Anastomotic false aneurysm (AFA) of the aorta or iliac artery is a rare but life-threatening complication of prosthetic grafts. We report a surgical case involving AFA of the right external iliac artery which developed at the site of peripheral anastomosis of the temporary bypass procedure used during prosthetic reconstruction of the descending aorta for dissecting aneurysm (DeBakey IIIb) 15 years previously. A 60-year-old woman was hospitalized with rapidly growing right lower abdominal mass. Computed tomography and angiography revealed that the mass was an anastomotic external iliac artery false aneurysm and surgery was performed. The AFA was exposed transperitoneally and resected with a part of the intact external iliac artery without complication. Anatomical reconstruction was completed with a prosthesis. The postoperative course was uneventful. We conclude that patients with retroperitoneal grafts require lifelong routine periodic follow-up and if an AFA is discovered, it should be resected.

We experienced unusual dilatation of gelatin-impregnated knitted Dacron prostheses after abdominal aortic aneurysm surgery. Therefore, we investigated dilatation of gelatin impregnated knitted Dacron grafts compared with other types of Dacron grafts after abdominal aortic aneurysm surgery. Eighteen grafts inserted after abdominal aortic aneurysm surgery were studied for to evaluate dilatation. Enhance CT was used to determine the external diameter of the most dilated portion of the abdominal aortic grafts and high speed plain CT was used to determine the most dilated internal diameter. The gelatin-impregnated knitted Dacron grafts dilated from 25% to 43.8% (mean 31.8±7.2%), significantly more than collagen impregnated woven Dacron grafts (p=0.0003). Moreover, high fever was frequently noticed after these grafts implantation (66.7%). Therefore, caution must be used concerning these implantation in aortic lesions and careful follow-up study should be performed after implantation.

CPK-MM, one of the CPK-isozyme, is divided into the three subbands (isoform) MMa, MMb, MMc. It has reported that in acute myocardial infarction serum MMa and MMa/MMc increased earlier than other myocardial intracellular enzyme, such as CPK-MB. In this study, we measured serum CPK, CPK isozyme, and CPK isoforms during and after open heart surgery and examined whether CPK isoforms would serve as a marker for myocardial damage during open heart surgery. CPK-MB peaked at 153.3±85.1IU six hours after cardiopulmonary bypass (CPB) was taken off and subsequently decreased. On the other hand, MMa/MMc peaked at 5.6±2.2 immediately after CPB was taken off. Moreover, we found that there was a statistically significant positive correlation (Y=24.46X+16.68, r=0.63, p<0.05) between MMa/MMc immediately after CPB was taken off and CPK-MB six hours after CPB was taken off. The maximum value of CPK-MB correlates with the degree of myocardial damage. Therfore, it is reasonable to suggest that the maximum value of MMa/MMc immediately after CPB is taken off also correlates with the degree of myocardial damage. We concluded that serum CPK isoform, especially MMa/MMc served as a marker to estimates the degree of myocardial damage in open heart surgery at an early stage.