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Objectives: Clostridioides difficile infection (CDI) is a leading cause of antimicrobial-associated colitis and is a global clinical concern. Probiotics are considered a CDI-preventive measure; however, highly inconsistent data have been previously reported. Thus, we evaluated the CDI-preventive effect of prescribed probiotics in high-risk older patients receiving antibiotics., Methods: Older patients (aged ≥65 years) admitted to the emergency department who received antibiotics between 2014 and 2017 were enrolled in this single-center retrospective cohort study. Propensity score-matched analysis was used to compare the CDI incidence in patients who took the prescribed probiotics within 2 days of receiving antibiotics for at least 7 days with those who did not. The rates of severe CDI and associated hospital mortality were also evaluated., Results: Among 6148 eligible patients, 221 were included in the prescribed probiotic group. A propensity score-matched (221 matched pairs) well-balanced for patient characteristics was obtained. The incidence of primary nosocomial CDI did not differ significantly between the prescribed and non-prescribed probiotic groups (0% [0/221] vs. 1.0% [2/221], p = 0.156). Of the 6148 eligible patients, 0.5% (30/6148) developed CDI, with a severe CDI rate of 33.3% (10/30). Furthermore, no CDI-associated in-hospital mortality was observed in the study cohort., Conclusions: The evidence from this study does not support recommendations for the routine use of prescribed probiotics to prevent primary CDI in older patients receiving antibiotics in situations where the CDI is infrequent., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Japanese Society of Chemotherapy, Japanese Association for Infectious Diseases, and Japanese Society for Infection Prevention and Control. Published by Elsevier Ltd. All rights reserved.)

High doses of daptomycin (DAP) (>6 mg/kg/day) have been preliminarily recommended in recent practical guidelines for methicillin-resistant Staphylococcus aureus infection, to achieve better clinical effects. While such doses can elevate the plasma trough concentration (Cmin) of DAP, there is an associated risk of creatine phosphokinase (CPK) elevation warranting further investigation. In the current study relationships between DAP Cmin and CPK elevation were investigated, and optimal DAP doses were determined. Plasma DAP concentrations were measured in 20 patients. Logistic regression analysis was performed to assess relationships between DAP Cmin and CPK elevation, then a population pharmacokinetic model of DAP was developed. To determine an optimal DAP dose a Monte Carlo simulation (MCS) was performed to minimize the risk of CPK elevation and maximize the probability of successful treatment. In logistic regression analysis DAP Cmin was significantly associated with CPK elevation (odds ratio 1.21, p = 0.048). With respect to dose-dependent increases in the probability of CPK elevation and exposure to DAP, MCS estimated an optimal DAP dose of 4-6 mg/kg/day, corresponding to a minimum inhibitory concentration (MIC) of ≤0.5 μg/mL. For an MIC of 1 μg/mL, MCS estimated an optimal DAP dose of 10 mg/kg/day. However, the probability of CPK elevation associated with high doses of DAP was higher than that associated with the approved doses. In cases where high doses of DAP are administered, close CPK monitoring is required and therapeutic drug monitoring of DAP may be desirable., (Copyright © 2019 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Plasmacytomas are a localized proliferation of plasma cells in the bone marrow and soft tissue. Extramedullary plasmacytomas are rare and typically solitary plasma cell neoplasms originating from extraosseous organs and tissues. A 31-year-old woman was referred to our hospital with a rapidly growing abnormal shadow on a chest roentgenogram. Chest computed tomography showed that the lesion was located in the anterior mediastinum. She underwent surgery, and the tumor was diagnosed as an extramedullary plasmacytoma. She remains well 2 years postoperatively without recurrence. An extremely rare case of an anterior mediastinal extramedullary plasmacytoma is presented., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Primary pulmonary lymphomas constitute up to 1% of all pulmonary malignancies. Patients with mucosa-associated lymphoid tissue (MALT) lymphoma represent approximately 90% of patients with primary pulmonary lymphoma. Most pulmonary MALT lymphomas are primary tumors. Pulmonary metastasis is extremely rare. A 65-year-old woman was diagnosed with a thyroid MALT lymphoma in 2008 and underwent total thyroidectomy, followed by chemotherapy. After 5 years of follow-up, she referred to our hospital with an abnormal shadow on a chest roentgenogram. She underwent video-assisted thoracoscopic surgery and was diagnosed with metastatic thyroid MALT lymphoma. Postoperatively, she was treated with chemotherapy, including rituximab, and is alive without recurrence., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Infected aortic aneurysm and inflammatory aortic aneurysm each account for a minor fraction of the total incidence of aortic aneurysm and are associated with periaortic inflammation. Despite the similarity, infected aortic aneurysm generally shows a more rapid change in clinical condition, leading to a fatal outcome; in addition, delayed diagnosis and misuse of corticosteroid or immunosuppressing drugs may lead to uncontrolled growth of microorganisms. Therefore, it is mandatory that detection of aortic aneurysm is followed by accurate differential diagnosis. In general, infected aortic aneurysm appears usually as a saccular form aneurysm with nodularity, irregular configuration; however, the differential diagnosis may not be easy sometimes for the following reasons: (1) symptoms, such as abdominal and/or back pain and fever, and blood test abnormalities, such as elevated C-reactive protein and enhanced erythrocyte sedimentation rate, are common in infected aortic aneurysm, but they are not found infrequently in inflammatory aortic aneurysm; (2) some inflammatory aortic aneurysms are immunoglobulin (Ig) G4-related, but not all of them; (3) the prevalence of IgG4 positivity in infected aortic aneurysm has not been well investigated; (4) enhanced uptake of 18F-fluorodeoxyglucose (FDG) by 18F-FDG-positron emission tomography may not distinguish between inflammation mediated by autoimmunity and that mediated by microorganism infection. Here we discuss the characteristics of these two forms of aortic aneurysm and the points of which we have to be aware before reaching a final diagnosis., (Copyright © 2011 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Infected aneurysm (IA) of the anterior interosseal artery (AIA), the first branch of the ulnar artery, is an infrequent but serious complication of infectious endocarditis (IE). We report a successful case of excision of IA arising from AIA. In this case, the IA expanded and adhered to the ulnar artery, resulting in occlusion of the ulnar artery. Reconstruction of the ulnar artery was not needed by the preoperative evaluation and the intraoperative occlusion testing. We discuss surgical treatment of IA following IE in upper extremities., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: In order to reduce the risk of cerebral embolism during aortic replacement through a left thoracotomy, we performed ascending or arch aortic cannulation (AAC) as well as early extracorporeal perfusion (EEP) under deep hypothermic circulatory arrest (DHCA). In this study we examined the effectiveness of these modifications in preventing cerebral embolism after distal arch replacement., Methods: Between January 2006 and March 2010, 40 patients underwent distal arch replacement through a left thoracotomy, using 2 pieces of an artificial graft. In all patients, AAC, EEP, and the open technique for aortic anastomosis were performed under DHCA. The AAC resulted in the proximal aortic perfusion from the proximal site of the diseased aorta. The EEP was induced by aortic distal perfusion from the side branch of a distal graft. After completion of the proximal anastomosis under EEP and DHCA, anastomosis between the proximal and distal grafts was made during rewarming. Neurologic deficit in the brain and spinal cord, as well as early surgical results, were clinically evaluated., Results: There was no permanent neurologic deficit after the surgery in the operative survivors. No patient had a stroke (0%). Temporary paraplegia and paraparesis occurred in 1 and 2 patients, respectively (7.7%); all 3 patients were able to walk prior to their discharge from hospital. Mortality in this series was 5.0% (2 of 40 patients); the cause of death was rupture of an esophageal ulcer and cardiogenic shock possibly due to myocardial infarction., Conclusions: The AAC and EEP, in addition to deep hypothermia and DHCA, minimized the risk of cerebral embolism after distal arch aortic replacement by the left lateral approach., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We encountered an extremely rare case of a saccular aneurysm of the descending aorta developing to the right of the spinal column with a normal left-sided aortic arch. An 80-year-old man was admitted to our hospital because of a saccular aneurysm of the right-sided descending aorta that had increased in diameter. Resection of the aneurysm and prosthetic graft replacement of the right-sided descending thoracic aorta were successfully performed under deep hypothermia through a right thoracotomy.

We report a surgical case of severe left ventricular dysfunction due to cardiac sarcoidosis. A 45-year-old man who underwent pacemaker implantation for complete atrioventricular block was admitted to the hospital because of dyspnea due to congestive heart failure. Echocardiography revealed a left ventricular ejection fraction of 11%, with severe mitral insufficiency and thinning of the ventricular septum. He was successfully treated by anteroseptal ventricular exclusion, mitral and tricuspid annuloplasty, and bi-ventricular pacing. Postoperative pathologic study revealed noncaseating granulomas. The patient was referred to a cardiologist for further treatment with prednisone.

Catechins have recently been reported to increase the cellular content of the hypoxia-inducible factor (HIF)-1alpha within mammalian cells. These catechins have a gallate moiety as a common structure. We now report that n-propyl gallate (nPG) also increases the HIF-1alpha protein in the rat heart-derived H9c2 cells. The increase was dose-dependent and reached a maximum at 2-4h after the addition of nPG to the cells. nPG did not change the HIF-1alpha mRNA level, showing that the increase is a posttranscriptional event. Although nPG did not inhibit the HIF prolyl hydroxylase, gallate, the hydrolysis product of nPG, inhibited the enzyme completely at submillimolar concentrations. Model building studies on the human HIF prolyl hydroxylase 2 showed that the two phenolate oxygen atoms of gallate form a chelate with the active site Fe(2+), while the carboxyl group of gallate forms a strong ionic/hydrogen bonding interaction with Arg383, explaining why nPG, which has an esterified carboxyl group, is unable to inhibit the hydroxylase. Together with the observation that gallate was detected in the H9c2 cells treated with nPG, these results suggest that nPG incorporated into the cells is hydrolyzed and the released gallate inhibits the HIF prolyl hydroxylase, thereby reducing the HIF degradation rate and increasing the HIF-1alpha content.

To examine the direct effects of tributyltin acetate (TBTA) on osteoclasts and osteoblasts, teleost scale, which has both osteoclasts and osteoblasts and is similar to mammalian membrane bone, was used in the present study. The activities of tartrate-resistant acid phosphatase and alkaline-phosphatase, as respective indicators of activity in both cells, were used. In freshwater teleost (goldfish) and marine teleosts (nibbler and wrasse), the osteoclastic activity in the scales did not change as a result of TBTA treatment (10(-9) to 10(-5) M). However, the osteoblastic activity decreased in the goldfish, nibbler, and wrasse after 6 h of incubation. In goldfish, even 10(-10) M of TBTA significantly inhibited the osteoblastic activity. The inhibitory activity in goldfish was stronger than that in nibbler and wrasse. Therefore, details of the mechanism were examined using goldfish. The mRNA expressions of the estrogen receptor and insulin-like growth factor-I, which participate in osteoblastic growth and differentiation, decreased in the TBTA-treated scales. However, the mRNA expression of metallothionein (MT), a metal-binding protein that protects the organism from heavy metal, increased much less than those of cadmium and methyl-mercury. Furthermore, we showed that the plasma calcium and hypocalcemic hormone (calcitonin) level increased in goldfish kept in water containing TBTA (10(-10) and 10(-8) M). The current data are the first to demonstrate that, in teleosts, TBTA inhibits osteoblastic activity without affecting osteoclastic activity and disrupts the calcium metabolism, including the calcemic hormone, in goldfish.

Ischemic tolerance, the phenomenon where a sublethal ischemic preconditioning protects the brain against a subsequent lethal ischemia, has been widely studied. Studies have been done on cerebral blood flow levels prior to the lethal ischemia, but the hemodynamic pattern after global ischemia with ischemic preconditioning has not been reported. Sequential changes in regional cerebral blood flow (rCBF) in gerbil hippocampus after 5 min global ischemia with or without 2 min ischemic preconditioning were studied to determine if ischemic preconditioning affects rCBF. Four different treatments were given: (1) sham-operated, (2) 2 min ischemia, (3) non-preconditioned, and (4) preconditioned. Groups (1) and (2) (both groups n = 5) were given a 24-h recovery period and the rCBF was measured for baseline values. 24 h after sham-operation (3) and 2 min ischemia (4), gerbils were subjected to 5 min ischemia followed by 1 h, 6 h, 1-day or 7-day reperfusion periods (all groups n = 5). Although no regional difference was observed in the recovery pattern of rCBF, the values of rCBF were significantly higher in the preconditioned group throughout whole brain regions including hippocampus. These results indicate that ischemic preconditioning facilitated the recovery of rCBF after 5 min global ischemia. It needs further study to determine whether the protecting effects of preconditioning relate to the early recovery of rCBF or not. However, our results could be interpreted that the early recovery of rCBF may lead to benefits for cell survival in the CA1 neuron, probably facilitating other protecting mechanisms.

Background: Fabry disease is an X-linked lysosomal storage disease resulting from deficient activity of the enzyme alpha-galacotsidase A. Accumulation of glycosphingolipids, especially globotriaosylceramide, leads to renal damage in Fabry disease. In patients with Fabry disease, the urinary sediment contains excreted glycosphingolipids. With enzyme replacement therapy for Fabry disease now currently available, we examined whether the urinary sediment could be used to noninvasively monitor effectiveness of enzyme replacement therapy., Methods: Four male patients with hemizygous classical Fabry disease received recombinant alpha-galactsidase A biweekly, and urinary sediments were assessed at 3-month intervals., Results: The morphologic and immunohistochemical changes in urinary sediment at 6 and 18 months suggested that accumulations of glycosphingolipids in renal tissues were cleared by enzyme replacement., Conclusion: Examination of urinary sediments could serve as noninvasive monitoring of the effect of therapy in patients with Fabry disease.

Wnt signaling plays a crucial role in the control of morphogenesis in several tissues. Herein, we describe the role of Wnt11 during cardiac differentiation of embryonic stem cells. First, we examined the expression profile of Wnt11 during the course of differentiation in embryoid bodies, and then compared its expression in retinoic acid-treated embryoid bodies with that in untreated. In differentiating embryoid bodies, Wnt11 expression rose along with that of Nkx2.5 expression and continued to increase. When the embryoid bodies were treated with retinoic acid, Wnt11 expression decreased in parallel with the decreased expression of cardiac genes. Further, treatment of embryoid bodies with medium containing Wnt11 increased the expression of cardiac marker genes. Based on these results, we propose that Wnt11 plays an important role for cardiac development by embryoid bodies, and may be a key regulator of cardiac muscle cell proliferation and differentiation during heart development.

The binding protein to a hypoglycosylated IgA1/Sepharose (IgA1-BP) could be prepared from human sera. IgG was a major component in the IgA1-BP. A Protein A column was used to remove the IgG; however, about half of the IgA1-BP was passed from the column [Biochem. Biophys. Res. Commun., 264 (1999) 424]. Quantitative analysis of the passed fraction (PAP) by laser nepherometry indicated that it was composed of a fairly large amount of IgA, IgM and complement C3 besides IgG. The relative content of IgG:IgA:IgM:C3:C4 was 25:10:41:22:2 in the PAP fraction. Meanwhile, the Protein A bound-fraction was essentially composed of IgG (78%) and IgM (19%). The total amount of IgA1-BP was not different between the sera from IgA nephropathy patients and other nephropathy patients. With respect to the IgA content in the IgA1-BP from IgA nephropathy patients, it was significantly higher than that from other nephropathy patients. It was found that the IgA1-BP from some IgA nephropathy patients contained a few micrograms of aberrant IgA per ml of serum. Thus, the obtained results suggested the preferential deposition of the self-aggregated IgA composed of hypoglycosylated IgA1 and co-deposition of IgG, IgM and C3 in the glomeruli in an IgA nephropathy patient., (Copyright 2002 Elsevier Science B.V.)

Background: A wide spectrum of operative techniques are applied in acute type A dissection. Most convey hospital mortality between 10% and 20%. In this high-risk setting, we believe that a conservative approach to the aortic root and the complete resection of the primary tear are important. We reviewed the results of this policy from our aortic surgery database., Methods: Between 1988 and December 2000, 95 acute type A dissection patients were operated on by one surgeon. They included 70 men and 25 women aged 37 to 81 years (mean 65 years). Six had Marfan syndrome. Aortic root restoration or replacement was performed during cooling, open arch repair during circulatory arrest, and hemostasis while rewarming. Eighty-seven patients had ascending aortic replacement with glue resuspension of the valve. Two others had had aortic valve replacement previously. Aortic root and partial arch replacement was performed in 6 Marfan patients. Eighteen patients had hemiarch replacement, and 6 had total arch replacement to excise the tear., Results: Five patients died in hospital (5.3% 30-day mortality) and another after early readmission for mediastinal infection (6.3% total mortality). There were no deaths from bleeding. Two patients required aortic valve replacement for aortic regurgitation 2.5 and 3.0 years postoperatively. Two others required total arch replacement and thromboexclusion procedures, respectively., Conclusions: Our policy of primary tear excision and preservation of the native aortic valve has resulted in low overall mortality. We still prefer to replace the aortic root in dissected Marfan patients. In this high-risk condition, hospital survival is of paramount importance. A conservative "pathology-oriented" approach helps to achieve this aim.

Background: The systemic inflammatory reaction (SIR) is assumed to be one of the factors that causes cerebral dysfunction after cardiopulmonary bypass (CPB). The aim of the present study was to evaluate the relationship between the SIR and postoperative cognitive performance at 5 days and 3 months., Methods: One hundred patients undergoing coronary artery bypass grafting were studied. Inflammatory markers and markers of coagulation and fibrinolysis were determined at several time points during and after the operation. Correlation analysis between maximum levels of the different markers and early and late performance was performed., Results: No overall association was found between the maximum levels of the inflammatory markers and early and late function., Conclusions: Notwithstanding limitations of statistical power established markers of systemic inflammatory reaction showed no relationship with outcome at 5-day or 3-month follow-up in this subset of patients.

Following aortic reimplantation of anomalous left coronary artery from the pulmonary artery in a 6-month-old infant, the heart failed to wean after prolonged supportive cardiopulmonary bypass and maximal inotropic support. We performed partial left ventriculectomy (Batista procedure) that halved left atrial pressure and enabled discontinuation of bypass. Postoperative recovery was then uneventful.

Background: Bioprostheses (BPs) are used to avoid anticoagulation after aortic valve replacement (AVR) in patients over 65 years of age. Stentless BPs offer established hemodynamic benefits. We sought to determine whether these advantages translate into improved survival., Methods: Between 1993 and 1997, follow-up data (for Food and Drug Administration submission) were collected prospectively for 160 consecutive, unselected hospital survivors who received the Freestyle valve (FS). Equivalent data were collected for 247 Carpentier-Edwards (CE) porcine xenograft patients. Detailed comparative statistical analysis was used to compare events and survival between the groups. Follow-up was 100% complete for the FS (5.2 years maximum; mean 3.2+/-1.0 years) group and 98% (7.2 years maximum; mean 3.8+/-2.0 years) for CE., Results: The groups were well matched in age (FS, 73+/-6 years; CE, 74+/-6 years), gender (FS, 58% male; CE, 62% male), ventricular function, and number of patients requiring coronary grafts (FS, 41%; CE, 37%). Actuarial survival at 5 years was 84% for FS versus 69% for CE (p = 0.023 Kaplan Meier, p = 0.009 Cox). Annual mortality rates were 3.6% for FS versus 7.1% for CE (p = 0.001). Thromboembolic rate was 0.8% per year for FS and 2.4% for CE (p = 0.024) without a difference in cardiac rhythm. Incidence of nonstructural dysfunction (paravalvular leak) was 0.2% for FS versus 1.3% for CE (p = 0.020)., Conclusions: By 5 years, the stentless valve patients had improved survival and reduced adverse events. Though differences in durability are yet to be proved, our findings support the use of stentless bioprostheses in this age group.

Background: Postoperative mediastinal false aneurysm is associated with a substantial morbidity and mortality. Surgical treatment is mandatory, although the individual approach varies according to the type of pathologic process, infection status, and site of origin of the aneurysm., Methods: Between April 1993 and February 1999, we treated 10 patients, aged 25 to 73 years, with anastomotic mediastinal false aneurysm originating from the proximal thoracic aorta. Nine had undergone prior operations on the ascending aorta (7, type A dissection repair; 1, aortitis; 1, root abscess) with a Dacron conduit (n = 5) or valved conduit (n = 4). The last patient had undergone valve replacement for excavating aortic root sepsis. False aneurysms were detected from 2 to 70 months after the most recent operation. Three patients had positive tissue cultures. The surgical procedure was direct suture repair of the disrupted anastomosis in 5, root or ascending aortic replacement with an aortic homograft in 4, and Dacron graft interposition in 1. Hypothermic low-flow perfusion with or without circulatory arrest was used in all patients., Results: There was one hospital death caused by staphylococcal mediastinitis. A false aneurysm recurred after direct suture repair in 2 patients with underlying type A dissection or aortitis. This resulted in one late death. One patient experienced a neurologic event during removal of an infected vascular graft. All 8 surviving patients are alive and well after a mean follow-up of 2 years. Three patients with mycotic false aneurysms remain free from infection after aortic homograft replacement., Conclusions: Mediastinal false aneurysms are surgically taxing. Low-flow hypothermic perfusion with or without circulatory arrest allows safe reentry. Radical surgery provides a satisfactory outcome in infected patients. Local repair of suture dehiscence in pathologic tissues may predispose to recurrence. We suspect that excessive use of formalin in gelatin-resorcin-formol glue may predispose to tissue necrosis.

A patient with acute fulminant lymphocytic myocarditis and cardiogenic shock was successfully treated by mechanical off loading of the left ventricle. A nonpulsatile left-heart bypass was undertaken with an implantable centrifugal blood pump. Careful weaning resulted in device removal on the seventh day. Left and right ventricular function is sustained at 7 months. Widespread application of this method depends on the availability of an inexpensive user friendly blood pump, appropriate weaning protocols and emerging strategies to promote sustainable myocardial recovery.

The role of albumin in bone metabolism was studied in Nagase analbuminemic (NA) rats. Serum calcium (Ca), inorganic phosphate (Pi) and magnesium (Mg) concentrations did not differ between female NA and control Sprague-Dawley (SD) rats at the time of ovariectomy (ovx), although serum ionized Ca was significantly lower in NA rats than in SD rats. Serum parathyroid hormone (PTH) and osteocalcin (OC) concentrations and urinary Ca excretion were significantly greater in NA rats than in SD rats, suggesting hyperparathyroidism and the resultant enhanced bone turnover in NA rats. Paradoxically, ovx increased serum PTH and OC in NA rats but not in SD rats. Ovx-induced exacerbation of hyperparathyroidism was confirmed by significantly greater conversion of 25-hydroxyvitamin D to 1, 25-dihydroxyvitamin D in ovx NA rats even after normalization to vitamin D-binding protein. Bone mineral density (BMD) in proximal tibia increased similarly in a time-dependent manner in sham-operated NA and SD rats. However, ovx ablated the time-dependent increase of BMD in SD rats and significantly decreased BMD in NA rats by 2 wk after ovx, resulting in a significantly lower BMD in ovx NA rats than in ovx SD rats. In summary, NA rats, which are analbuminemic with compensatory increases in lipid and protein synthesis, developed hyperparathyroidism, possibly due to an increase in serum Pi and a reduction of ionized Ca, and ovx induced a greater BMD reduction in NA rats than in SD rats, probably by exacerbating hyperparathyroidism.

We describe a novel method for surgical repair of giant right coronary aneurysm. Instead of aneurysm ligation and coronary bypass we mobilized the inflow and outflow and performed end-to-end anastomosis. This preserved the native vessel. Restudy in both patients confirmed the effectiveness of this technique.

We describe a technique to transfer an anomalous left coronary artery originating in the left posterior pulmonary sinus to the aorta. Both autogenous aortic and pulmonary arterial flaps create an extended left main stem without the disadvantages of standard rerouting techniques and full potential for growth remains.

Background: Coarctation occurring within the aortic arch is rare and may present difficulties during surgical repair. We describe the operative technique and outcome in 6 patients with this unusual anomaly., Methods: Five patients had antegrade perfusion with circulatory arrest. Three patients with presubclavian narrowing (one presenting with type B dissection) were operated through extended left thoracotomy. Two precarotid and paracarotid lesions were approached through a median sternotomy. All patients were perfused antegradely from the ascending aorta and operated with hypothermic circulatory arrest. One patient who had a complex presubclavian coarctation after two previous repairs received an ascending aorta to abdominal aorta bypass graft without cardiopulmonary bypass., Results: All patients survived operation and are well at a mean follow-up of 3.3 years after the procedure. None had cerebral problems or spinal cord injury. Renal function was unchanged. The mean (+/- standard error of the mean) resting gradient across the coarctation decreased from 42+/-4.0 mm Hg to 6+/-1.2 mm Hg (p = 0.0004)., Conclusions: Hypothermic circulatory arrest using antegrade ascending aortic perfusion allows safe and effective repair of mid-arch coarctation. Complicated reoperations can be managed safely using ascending-to-abdominal aortic bypass.

We describe a technique to relieve tension on the reimplanted right coronary button during aortic root replacement. A hood is fashioned from autogenous aorta or pericardium to provide a funnel inflow to the coronary ostium. The technique can be used either electively or as a rescue maneuver in the event of right ventricular ischemia.

Intravenous leiomyomatosis is a condition characterized by intravenous growth of histologically benign smooth muscle tumor, originating in the uterus. A case of intravenous leiomyomatosis with right atrial extension in a 64-year-old woman is described. The atrial tumor was successfully removed with a single-stage approach via sternolaparotomy and total circulatory arrest using cardiopulmonary bypass.

We performed aortic root replacement using partial upper sternotomy in a patient with Marfan's syndrome. This approach was necessary because of severe pectus excavatum and spinal deformities. Although this method is technically feasible, we would not advocate it for routine use.

Background: There are few guidelines for surgical intervention late after unoperated traumatic aortic rupture. We reviewed our experience and the literature to determine when and how to operate., Methods: Between 1987 and 1997, we treated 9 patients aged 22 to 82 years with chronic traumatic aneurysm. Seven patients underwent aneurysm resection. Two patients have not been operated on. The injury-to-operation interval ranged from 8 weeks to 18 years (mean, 4.1 years). One patient underwent median sternotomy and patch repair during hypothermic circulatory arrest. Six patients underwent left thoracotomy: 2 were operated on with left atrio-femoral bypass, and 4 with hypothermic circulatory arrest and ascending aortic cannulation., Results: There was no surgical mortality or morbidity. The 2 patients who were not operated on remained asymptomatic without radiologic change in the aneurysm after follow-up of 2 and 9 years., Conclusions: From this limited experience and literature review, we make the following subjective observations: (1) all patients with new symptoms should be operated on promptly, and (2) asymptomatic densely calcified aneurysms detected more than 2 years after the accident can be observed by repeated tomography unless new symptoms arise.

We describe a patient with left atrial myxoma followed by a second lesion in the left ventricle. Previous reports of "recurrent" myxoma were studied, with the following conclusions: There is little evidence for the process of myxoma seeding, local recurrence can occur through inadequate resection or malignant change, and many alleged recurrences are at a different site and multifocal disease occurs frequently in the familial setting.

We describe successful management of pulmonary hypertension with a reversible aorto-pulmonary (central) shunt and inhaled nitric oxide gas after truncus arteriosus repair. A temporary central shunt may provide a lifeline in those cases refractory to pharmacologic pulmonary vasodilation as long as marginal systemic oxygenation can be maintained.

We used a Freestyle (Medtronic, Minneapolis, MN) porcine root to replace a regurgitant aortic valve and repair acute type A dissection. A Hemashield (Meadox Medicals, Oakland, NJ) graft was used to replace the ascending aorta with the "open anastomosis" technique. This method is a valuable alternative to conventional root replacement in acute type A dissection.

Background: Driveline infection limits the event-free survival of patients with a left ventricular assist device. With the evolving prospect of improved left ventricular assist devices in the bridge-to-transplantation or recovery setting, we sought to reduce the risk of driveline complications., Methods: As part of the Oxford Jarvik 2000 research program, we developed a carbon and then titanium pedestal to transmit the electric wires through the skin. In a sheep model, the pedestal was brought out through the skin of the shoulder (n = 10) or the scalp (n = 9) with underlying fixation to the skull. Exit wounds were carefully inspected for healing and infection. Power cable durability tests were performed in 6 additional animals without an implanted pump., Results: The cumulative observation period was 1,491 days (mean time, 78 days; range, 14 days to 198 days). There was no difference in observation period between the two groups. Infection (n = 2) and impaired healing (n = 5) occurred in the mobile tissues at the shoulder. Skull-mounted pedestals were free from infection or healing problems. The electric cables were not interrupted by repeated neck flexion (cumulative observation period, 588 days). The carbon pedestal was replaced by a titanium pedestal when the head butting of the sheep fractured the carbon., Conclusions: The combination of rigid fixation and highly vascular scalp skin reduces the risk of percutaneous driveline infection and may solve an important outstanding problem in use of left ventricular assist devices.

The management of prosthetic graft infection is still challenging. We report in situ repair of an infected mediastinal false aneurysm by ascending aortic replacement with a fresh aortic homograft.

Background: Recent reports have documented left ventricular recovery in patients with dilated cardiomyopathy off-loaded long term with a left ventricular assist device. We sought to document the natural history of left ventricular recovery., Methods: We implanted the TCI left ventricular assist device without the intention to perform transplantation in 2 patients with dilated cardiomyopathy who had been rejected for transplantation. Both were in New York Heart Association functional class IV and had renal failure. One was a diabetic. We studied left ventricular function with detailed echocardiography at 4, 6, and 8 weeks postoperatively., Results: With the left ventricular assist device turned off, we observed a progressive increase in myocardial contractility beginning as early as 4 weeks after implantation and improving progressively. Histologic examination showed resolution of myocytolysis in both patients., Conclusions: Left ventricular recovery begins earlier than was previously suspected. Mechanical bridge to myocardial recovery is a potential approach to therapy for such patients.

Congenital diverticulum of the left ventricle is rare, and rupture of such a diverticulum is even more rare. We describe successful surgical repair of a ruptured left ventricular diverticulum in an 11-month-old infant.

Surgical reduction has been proposed to reduce left ventricular wall stress and improve geometry in patients with left ventricular failure. We describe 2 cases of direct surgical reduction in ischemic cardiomyopathy. Although left ventricular function improved in both, late ventricular dysrhythmia negated the result.

Background: We consider operative survival as the primary objective in acute type A dissection and believe that virtually all native aortic valves can be conserved. We sought to answer the question: "Does glue repair improve the long-term stability of proximal aortic repair?", Methods: We retrospectively studied 64 patients with an acute type A dissection, an ascending aortic tear, and aortic regurgitation operated on by the same surgeon between 1988 and 1996. Three had Marfan's syndrome and 2 had a bicuspid valve. The valves in all patients without Marfan's syndrome were repaired with gelatin-resorcinol-formol glue. The valve and root were reinvestigated by echocardiography. Some patients underwent nuclear magnetic resonance imaging., Results: There were four hospital (6%) and three late deaths. Aortic root reoperation was required in 2 of the 60 survivors (3.3%) and operation on the distal aorta in 2. Root reoperations were required within 3 years. The remaining proximal repairs remained stable., Conclusions: The native aortic valve can be conserved in most patients, and glue repair is durable. Simple root repair is associated with a low operative mortality.

We describe a patient with congenital absence of a single pulmonary valve cusp. A monocusp aortic homograft was used to repair the valve.

An infected tricuspid valve was successfully replaced with a fresh mitral homograft. This operation is preferable to valvectomy alone or the use of a stented prosthesis in terms of hemodynamics and resistance to infection.

Stenting seems to be a definitive procedure after failed balloon coronary angioplasty. This report describes a case of redo coronary bypass grafting and concomitant resection of enlarging false aneurysm of a saphenous vein graft that developed secondary to stenting for recurrent stenosis after serial percutaneous transluminal coronary angioplasty. It warns us of a pitfall in catheter intervention in an aged saphenous vein graft.

Direct interactions of Friend spleen focus-forming virus glycoprotein gp55 with either erythropoietin receptor (EpoR) or interleukin (IL)2 receptor beta chain (IL2R) (but not with IL3 receptor) have been reported to induce factor-independent prolonged proliferation of erythroid or lymphoid cells. In order to clarify the molecular mechanism by which EpoR-gp55 complex transmits an aberrant growth signal in the absence of erythropoietin, various chimeric receptors constituted with IL2R, EpoR or IL3 receptor were constructed. It was found that coexpression of gp55 and the chimeric receptors containing the cytoplasmic domains of EpoR and the extracellular domains of IL3 (or IL2) receptor in IL3-dependent Ba/F3 cells results in factor-independent growth. Since gp55 in cell membrane has only a two amino acid tail in the cytoplasmic domains and thus cannot interact with EpoR in cytoplasm, our data suggest that gp55 does not bind EpoR directly but interacts with EpoR through third membrane component(s).