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Surgery for acute type A aortic dissection with mesenteric malperfusion is challenging. Although the peripheral-reperfusion-first strategy has shown good results, more discussion regarding indicated patients is needed. This study aimed to describe the imaging features and surgical outcomes of mesenteric malperfusion and to clarify which cases should be considered for the peripheral-reperfusion-first strategy. A total of 200 patients underwent emergent aortic repair for acute type A aortic dissection at our institution between October 2011 and July 2019. Superior mesenteric artery occlusion on preoperative contrast-enhanced computed tomography was detected in 12 patients, who were categorized into two groups based on enhancement (n = 7) or non-enhancement (n = 5) of the superior mesenteric artery peripheral branches. Operative outcomes after central repair were compared between groups. Four patients in the enhanced group had no postoperative abdominal complications, and three patients required superior mesenteric artery bypass grafting with the central-repair-first strategy. However, all patients in the enhanced group survived and did not require intestinal resection. In contrast, four patients (80%) in the non-enhanced group had intestinal necrosis, three patients required intestinal resection, and one patient died from multiple organ failure. The presence or absence of an enhancement of the peripheral superior mesenteric artery by the collateral network could be helpful for decision-making. The central-repair-first strategy may be permitted in patients with enhanced peripheral branches. Conversely, in patients with non-enhanced peripheral branches, a more invasive assessment should be considered before central aortic repair, and peripheral-reperfusion-first strategy may be required.

Background Reoperative aortic valve replacement (AVR) is associated with increased mortality compared with initial surgery, and a smaller valve might be implanted during repeat AVR (re-AVR; AVR after prior AVR). We describe the clinical outcomes and incidence of prosthesis-patient mismatches (PPM) after reoperative AVR. Methods Among 113 patients who underwent reoperative AVR between 2007 and 2018, 44 underwent re-AVR and 69 underwent a first replacement of a diseased natural valve after any cardiac surgery except AVR (primary AVR). We then compared early and late outcomes, the impact of re-AVR on the effective orifice areas (EOA), and the incidence and influence of PPM on reoperative AVR. Results Hospital mortality was 2.7%, and the overall 1-, 3-, and 5-year survival rates were 95, 91 and 86%, respectively. The reference EOA of the newly implanted valve was smaller than that of the previous valve (1.4 ± 0.3 vs. 1.6 ± 0.3 cm2, p p = 0.04) and indexed EOA was smaller (0.92 ± 0.26 vs. 1.06 ± 0.36 cm2/m2, p = 0.04) during re-AVR than primary AVR, whereas the incidence of PPM was similar (38.7% vs. 34.8%, p = 0.87) between the groups. Conclusions The clinical outcomes of reoperative AVR were acceptable. Although the reference EOA of new implanted valves was smaller than that of previous valves, re-AVR did not increase the incidence of PPM. These findings might serve as a guide for future decisions regarding the surgical approach to treating degenerated prosthetic valves.

We aimed to determine the outcomes of contemporary mitral valve replacement (MVR) in octogenarians, for rational treatment selection in a patient cohort.Between 2007 and 2018, 656 consecutive MVRs were performed. Among these cases, 109 patients were aged 80 years or older, and 547 patients were younger than 80 years. Isolated MVRs were performed in 211 patients, of whom 36 were aged 80 years or older. Perioperative mortality and complications were compared between the two groups, adjusted by propensity score.In-hospital mortality of the entire MVR (80: 26 [4.8%] vs. ≥80: 6 [5.5%], p = .81) and isolated MVR (80: 6 [3.4%] vs. ≥80: 1 [2.8%], p .99) groups were similar. Age80 years did not influence in-hospital mortality (hazard ratio [HR], 1.07; 95% confidence interval [CI], 0.36-3.14, p = .9), stroke (HR, 1.12; 95% CI, 0.19-6.71, p = .9), hemodialysis (HR, 1.44; 95% CI, 0.45-4.66, p = .54), or prolonged ventilation (HR, 1.61; 95% CI, 0.81-3.23, p = .18), but influenced the incidence of reopening for bleeding (HR, 3.97; 95% CI, 1.11-14.19, p = .03). Cox proportional hazard model results showed that age80 years did not affect cardiac death (HR, 1.45, 95% CI: 0.67-3.12, p = .35), bleeding events (HR, 1.89, 95% CI: 0.84-4.27, p = .13), or stroke (HR, 1.51, 95% CI: 0.54-4.21, p = .44) during the follow-up period.The perioperative and follow-up outcomes of MVR in octogenarians were not inferior to those of younger patients. We should not hesitate to conduct MVR on the grounds of old age.

A calcified amorphous tumor (CAT) is a rare, non-neoplastic cardiac mass frequently located in cardiac chambers, especially the mitral valve or annulus. Here, we report an exceedingly rare case of CAT as an atypical mobile mass in the ascending aorta in a 62-year-old man who was on hemodialysis for 11 years. The CAT grew rapidly within 3 months. We resected the mass, and he was discharged with no complications. This report shows that the CAT can grow rapidly, even in the aorta, and provides important information on the progression of this rare disease and its clinical features.

Calcified amorphous tumor (CAT) is a nonneoplastic cardiac tumor that can be located in any of the four cardiac chambers, but is predominantly detected on the mitral valve. We report a rare case of CAT originating from the mitral and aortic valves. A 69-year-old woman with end-stage renal disease, hypertension, and diabetes mellitus was referred to our hospital for the evaluation of cardiac masses found incidentally on screening transthoracic echocardiography. She had no symptoms, including fever and neurological deficits, and her blood cultures were negative. Echocardiography revealed mobile masses arising from the mitral and aortic valves. We performed surgical excision and histopathologically diagnosed the masses with cardiac CATs. Mobile and pedunculated CAT frequently causes systemic embolization, and thus, complete surgical excision is recommended in such a case.

Background There are no reports of midterm outcomes after mitral valve replacement with a 25-mm bioprosthesis in a large series of patients. This study aimed to examine perioperative and midterm outcomes of bioprosthetic valve choice, porcine or bovine pericardial, in the mitral position, focusing on 25-mm valves. Methods From 2007 to 2018, 467 patients received a mitral bioprosthesis, with or without concomitant procedures. Of these, 111 (23.8%) were porcine, and 356 (76.2%) were bovine pericardial, and 219 patients (46.9%) received a 25-mm valve. A propensity-matched cohort of 192 patients was used for outcome analyses. The influence of the valve type on midterm survival and incidence of cardiac death was assessed. Similarly, subanalysis stratified by valve size was conducted. Results In matched patients, there were no differences in midterm survival and incidence of cardiac death between the two groups (log-rank test; p = .268 and p = .097, respectively). There were no differences in midterm survival and incidence of cardiac death between the 25-mm valve and larger valve (log-rank test; p = .563 and p = .597, respectively). The Cox proportional-hazards model revealed that the valve type and 25-mm valve did not affect midterm survival (p = .487 and p = .375, respectively) and incidence of cardiac death (p = .678 and p = .562, respectively). Conclusions The choice of a porcine or bovine pericardial bioprosthesis does not affect midterm survival and cardiac death. The 25-mm valves, whether bovine or porcine, could be an appropriate alternative when the patient's body size is small.

The frozen elephant-trunk (FET) procedure is used widely in total aortic arch replacement (TAR) surgery; however, its safety, effectiveness, and long-term outcomes compared with those of the conventional elephant trunk (cET) procedure for degenerative aneurysms are unclear. Between July, 2011 and August, 2019, 126 patients underwent elective total aortic arch replacement at our institution. We compared the short- and mid-term outcomes of 60 patients who underwent the FET procedure (FET group) with those of 66 patients who underwent cET (cET group). The in-hospital mortality rate tended to be lower in the FET group than in the cET group (p = 0.12). There were two cases of paraplegia (3.3%) in the FET group and in none in the cET group. The all-cause mortality at the 3-year follow-up did not differ significantly between the groups (p = 0.31). The FET group required more unexpected interventions at the surgical site in the mid-term period. FET was associated with a shorter operative time and lower surgical mortality than cET. Although the mid-term total aortic arch replacement outcomes of FET were acceptable, careful imaging observation is necessary because reinterventions were required more frequently.

The effect of patient-prosthesis mismatch (PPM) on late outcomes after mitral valve replacement (MVR) remains unclear. We evaluated the impact of PPM after MVR on the late survival using propensity score matching analysis. From 2007 to 2018, 660 consecutive MVRs were performed. Effective orifice areas were obtained from a literature review of in vivo echocardiographic data, and mitral PPM was defined as an effective orifice area index of ≤1.2 cm2/m2. Propensity score matching yielded a cohort of 126 patients with PPM and 126 patients without PPM. Mitral PPM was found in 37.8% of the patients. In the whole matched patients, there were no differences in late survival (log-rank test, P = 0.629) between 2 groups. Patients aged ≤70 years and those aged >70 years had no differences in late survival (log-rank test, P = 0.073 and 0.572). The Cox proportional hazards model for the overall survival showed that mitral PPM tended to decrease survival in patients aged ≤70 years (P = 0.084, hazard ratio [HR] 2.647, 95% CI: 0.876–7.994). Mitral PPM did not adversely affect long-term survival. There may be a tendency of adverse impact on late survival in patients aged ≤70 years. Implanting a safe size rather than larger size prosthesis in mitral position may be an appropriate option in older patients.

Revascularization to infarcted area after left ventricular free-wall rupture has been controversial. A 68-year-old man with acute myocardial infarction presented to our hospital and developed a left ventricular free-wall rupture. We repaired the left ventricular oozing rupture without culprit artery revascularization, however, followed by papillary muscle rupture and left ventricular blow-out rupture, which resulted in sudden death.

Background The right gastroepiploic artery (RGEA) is often used for coronary artery bypass grafting (CABG) in Japan. As gastric cancer has a high prevalence in many Asian countries, we investigated problems with surgery for gastric cancer after CABG using the RGEA. Methods A total of 860 patients underwent CABG using the RGEA between January 1997 and December 2006. Of these, 13 patients underwent surgery for gastric cancer after CABG. In all cases, the RGEA was harvested by the skeletonization technique, and an antegastric route was used for the anastomosis. Results Dissection for the No. 6 lymph node was not performed in all cases because of the risk of graft injury. Graft injury during gastric surgery occurred in one patient and post-operative ventricular fibrillation (VF) was observed in two patients. One case of hospital death due to VF and two cases of remote death were encountered. Conclusions In planning a resection for gastric cancer following a CABG with a patent RGEA graft, the potential for graft injury must be anticipated. In advanced stages of gastric cancer when the RGEA needs to be resected to dissect the No.6 lymph node, a pre-operative percutaneous coronary intervention or a reoperative CABG may be indicated.

As support times for left ventricular assist devices (LVADs) become longer, several complications requiring device exchange may occur. To our knowledge, this is the first Canadian report regarding implantable LVAD exchange.We retrospectively reviewed the cases of consecutive, unique patients implanted with an LVAD between June 2006 and October 2015 at Toronto General Hospital.In total, 122 patients were impanted with an LVAD during the study period. Eight patients required LVAD exchange, and 1 patient had 2 replacements (9 of 122, 7.3%). There were 7 HeartMate II (HMII), 1 HVAD and 1 DuraHeart pumps exchanged. Two of these exchanges occurred early at the time of initial implant, whereas 7 occurred late (range 8-623 d). Six exchanges were made owing to pump thrombosis. Of the 3 exchanges made for other causes, 1 HMII exchange was owing to a driveline fracture, 1 DuraHeart patient had early inflow obstruction requiring exchange to HMII at the initial implant, and the third had a suspected inflow obstruction with no evidence of thrombosis at the time of the procedure. The mean support time before exchange was 225 days, and time from exchange to transplant, death or ongoing support was 245 days. Three patients were successfully bridged to transplant, and at the time of data collection 2 were supported awaiting transplant. Three patients died after a mean duration of 394.3 days (range 78-673 d) of support postreplacement. Four cases were successfully performed using a subcostal approach.Pump thrombosis is the most common cause for LVAD exchange, which can be performed with acceptable morbidity and mortality. The subcostal approach may be the preferred procedure for an HMII exchange when indicated.À mesure que la durée d'utilisation des dispositifs d'assistance ventriculaire gauche (DAVG) augmente, plusieurs complications nécessitant un remplacement du dispositif peuvent survenir. À notre connaissance, il s'agit du premier rapport canadien concernant le remplacement des DAVG implantables.Nous avons passé en revue de manière rétrospective les cas individuels consécutifs de patients à qui on a implanté un DAVG entre juin 2006 et octobre 2015 à l'Hôpital Général de Toronto.En tout, 122 patients ont reçu un DAVG pendant la période de l'étude. Huit patients ont eu besoin d'un remplacement de DAVG et 1 patient a eu besoin de 2 remplacements (9 sur 122, 7,3 %). Sept dispositifs HeartMate II (HMII), 1 dispositif HVAD et 1 dispositif DuraHeart ont été remplacés. Deux de ces remplacements sont survenus peu de temps après la pose initiale du dispositif, tandis que les 7 autres se sont produits plus tardivement (dans les 8 à 623 jours suivants). Six remplacements ont été effectués en raison d'une thrombose de la pompe. Parmi les 3 remplacements effectués pour d'autres raisons, 1 dispositif HMII a été remplacé en raison d'un bris de la ligne d'activation, 1 dispositif DuraHeart a présenté une obstruction précoce du flux entrant nécessitant la pose d'un HMII dès l'implantation initiale, et le troisième présentait une obstruction présumée du flux entrant sans signe de thrombose au moment de l'intervention. La durée moyenne d'utilisation avant le remplacement du dispositif a été de 225 jours, et l'intervalle entre le remplacement et la transplantation, le décès ou la décision de maintenir l'assistance a été de 245 jours. L'appareil a permis une transition réussie jusqu'à la transplantation chez 3 patients, et au moment de la collecte des données, 2 patients porteurs d'un DAVG étaient en attente d'une transplantation. Trois patients sont décédés après une durée moyenne de 394,3 jours (entre 78 et 673 jours) d'assistance post-remplacement. Quatre remplacements ont été effectués avec succès par une approche sous-costale.La thrombose de la pompe est la cause la plus fréquente de remplacement d'un DAVG; le remplacement peut être effectué avec des taux de morbidité et de mortalité acceptables. L'approche sous-costale serait à privilégier lorsqu'un remplacement de HMII est indiqué.

Background: The semiquantitative Clinical Frailty Scale (CFS) is a simple tool to assess patients’ frailty and has been shown to correlate with mortality in elderly patients even when evaluated by nongeriatricians. The aim of the current study was to determine the prognostic value of CFS in patients who underwent transcatheter aortic valve replacement. Methods: We utilized the OCEAN (Optimized Catheter Valvular Intervention) Japanese multicenter registry to review data of 1215 patients who underwent transcatheter aortic valve replacement. Patients were categorized into 5 groups based on the CFS stages: CFS 1-3, CFS 4, CFS 5, CFS 6, and CFS ≥7. We subsequently evaluated the relationship between CFS grading and other indicators of frailty, including body mass index, serum albumin, gait speed, and mean hand grip. We also assessed differences in baseline characteristics, procedural outcomes, and early and midterm mortality among the 5 groups. Results: Patient distribution into the 5 CFS groups was as follows: 38.0% (CFS 1-3), 32.9% (CFS4), 15.1% (CFS 5), 10.0% (CFS 6), and 4.0% (CFS ≥7). The CFS grade showed significant correlation with body mass index (Spearman’s ρ=−0.077, P =0.007), albumin (ρ=−0.22, P P P P P Conclusions: In addition to reflecting the degree of frailty, the CFS was a useful marker for predicting late mortality in an elderly transcatheter aortic valve replacement cohort.

Background: Graft Imaging to Improve Patency (GRIIP), a single-center, randomized blinded clinical trial, reported that intraoperative graft assessment with graft revision according to a priori criteria of transit time flowmetry (TTF) and intraoperative fluorescent angiography did not improve graft patency at one year after coronary artery bypass grafting (CABG) when compared with standard intraoperative management. The objective of this study is to investigate whether other TTF values are more predictive of the saphenous vein graft (SVG) failure and/or clinical outcomes. Methods: This is a case control retrospective study of 65 SVGs from 44 patients from GRIIP. Study outcomes were graft patency at 12 months and major adverse cardiac events (MACE; death, myocardial infarction, repeat revascularization). Results: Twenty-two SVGs were occluded. In receiver operating characteristic curve analysis, TTF mean flow was significantly predictive of one-year SVG failure (area under the curve = 0.698, p

The aim of this study was to investigate early and late outcomes for open stent-graft treatment, which was introduced as a less-invasive technique for thoracic aortic aneurysm of the distal arch, and to clarify the validity of and indications for this treatment.We retrospectively investigated 38 patients with thoracic aortic aneurysm of the distal arch who underwent open stent-graft placement at our hospital between June 2000 and September 2006.Five patients died in hospital (hospital mortality 13.2%). Age at the time of surgery and onset of postoperative paraplegia were identified as risk factors. Four patients (10.5%) had postoperative paraplegia, but no significant risk factors were seen. The size of the aneurysm was clearly reduced in 18 of the 25 patients (75.8%), in whom computed tomography was performed after discharge, and late outcomes were good. Mural thrombus thickness on the stent landing zone of4 mm was a predictor for aneurysm shrinkage. Seven patients died during the late period, and the 5-year survival rate among hospital survivors was 80.1%.Early outcomes for open stent-graft are not necessarily good, and late survival is also not excellent. Open stent-graft thus cannot be regarded as an ideal technique for all patients with distal aortic arch aneurysm. However, after aneurysm shrinkage was confirmed during the early period, late outcomes were good. Absence of thick mural thrombus on the stent landing zone may represent a good indication for open stentgraft surgery.

先天性食道気管支瘻に合併した感染性胸部大動脈仮性瘤の1例を経験したので報告する．症例は74歳の男性．6年前より慢性腎不全に対して血液透析を行っていた．背部痛を訴えて来院し，胸部 CT により感染性胸部大動脈仮性瘤と診断された．大動脈の広範な石灰化を有する透析患者に対するグラフト置換術のリスクと感染の存在下におけるステントグラフト使用のリスクの双方を考慮した結果，ステントグラフト内挿術を施行した．術後に遷延する肺炎，飲水時の咳，嚥下困難をみとめた．上部消化管内視鏡，気管支鏡により食道気管支瘻と診断された．食道気管支瘻に対する根治術を予定していたが，術後64日目胸部大動脈仮性瘤の再出血により死亡した．病理組織検査の結果，先天性食道気管支瘻と診断した．

Background Graft stenosis may be associated with future graft failure. The purpose of this investigation was to compare graft stenosis between radial artery (RA) grafts and saphenous vein grafts (SVGs) at least 5 years postoperatively using the multicenter Radial Artery Patency Study (RAPS) data. Methods Two hundred thirty-four patients underwent late invasive angiography after coronary artery bypass operations. The study population consists of 163 patients with thrombolysis in myocardial infarction (TIMI) 3 flow of both the RA graft and study SVGs. Angiograms were reviewed centrally and in a blinded fashion. Graft stenosis was recorded for the proximal anastomosis, graft body, and distal anastomosis; significant stenosis was defined as greater than or equal to 50%. Major adverse cardiac events (MACE) were reported in patients with and those without significant graft stenosis. Results There was no difference in significant graft stenosis of the patent RA grafts and SVGs (14 of 163 [8.6%] versus 19 of 163 [11.7%]) or in the proximal anastomosis (5 of 163 [3.1%] versus 5 of 163 [3.1%]), graft body (6 of 163 [3.7%] versus 13 of 163 [8.0%]), or distal anastomosis (4 of 163 [2.5%] versus 5 of 163 [3.1%]) considered separately. However, the overall burden of graft body disease was higher in SVGs ( p = 0.03). MACE was higher in patients with significant graft stenosis than in patients without stenosis (10 of 28 [35.7%] versus 7 of 135 [5.2%]; p Conclusions There was no significant difference in the rates of significant stenosis of patent RA grafts and SVGs more than 5 years postoperatively. However, the burden of graft body stenosis was less in RA grafts compared with SVGs, suggesting that the RA grafts will continue to outperform the SVGs late after operation.

Transfusion-associated graft-versus-host disease (TA-GVHD) is a rare complication of blood transfusion. The clinicolaboratory features of TA-GVHD and the relative contributions of recipient and component factors remain poorly understood. We conducted a systematic review of TA-GVHD reports. The HLA relationship between donor and recipient was classified as D = 0 when no donor antigens were foreign to the recipient vs D ≥ 1 when ≥1 donor antigen disparity occurred. We identified 348 unique cases. Criteria for component irradiation were met in 48.9% of cases (34.5% immune-compromised, 14.4% related-donor), although nonirradiated components were transfused in the vast majority of these (97.6%). Components were typically whole blood and red cells. When reported, component storage duration was ≤10 days in 94%, and 23 (6.6%) were leukoreduced (10 bedside, 2 prestorage, and 11 unknown). Among 84 cases with HLA data available, the category of D = 0 was present in 60 patients (71%) at either HLA class I or II loci and was more common among recipients without traditional indications for component irradiation. These data challenge the historic emphasis on host immune defects in the pathogenesis of TA-GVHD. The dominant mechanism of TA-GVHD in both immunocompetent and compromised hosts is exposure to viable donor lymphocytes not recognized as foreign by, but able to respond against, the recipient.

Objectives The study objective was to determine the impact of diabetes on radial artery and saphenous vein graft occlusion and clinical outcomes more than 5 years after coronary artery bypass surgery in the multicenter Radial Artery Patency Study (NCT00187356). Methods A total of 529 patients aged less than 80 years with triple-vessel disease undergoing coronary bypass surgery participated in this study. Angiographic follow-up occurred more than 5 years after surgery with annual clinical follow-up. The primary objective was to compare the proportion of complete graft occlusion between radial artery and saphenous vein grafts among diabetic and nondiabetic persons. Additional objectives included determining predictors of complete graft occlusion and comparison of major adverse cardiac events defined by cardiac death, late myocardial infarction, and reintervention. Results There were 148 of 529 patients (27.8%) with diabetes; 269 patients (83/269 [30.9%] diabetic) underwent late angiography at mean of 7.7 ± 1.5 years after surgery. In diabetic patients, the proportion of complete graft occlusion was significantly lower in the radial grafts (4/83 [4.8%]) than in the saphenous grafts (21/83 [25.3%]) ( P = .0004), and this was similar in nondiabetic patients ( P = .19). Multivariate modeling showed that the use of the radial artery and high-grade target vessel stenosis were protective against late graft occlusion, whereas female gender, smoking history, and elevated creatinine were associated with an increased risk; interaction between diabetic status and conduit type also was significant ( P = .02). Major adverse cardiac events were higher in diabetic patients (23/148 [15.5%] vs 35/381 [9.2%], P = .04). Conclusions The use of the radial artery should be strongly considered in diabetic patients undergoing coronary bypass surgery, especially with high-grade target vessel stenosis.

A 60-year-old man presented with intense right knee and thigh pain as well as weakness in his right lower extremity. Two months prior, he had sudden onset of severe low back pain and presented to his local physician, where he was diagnosed with lumbar spondylolisthesis. The back pain remitted soon thereafter, but he subsequently developed right knee and thigh pain. Upon presentation to our hospital, he denied having lower back pain or abdominal pain and had intact pulses in his lower extremities. His abdomen was soft and without tenderness, but a pulsating mass was palpated in the periumbilical region. Computerized tomography scan revealed an abdominal aortic aneurysm (AAA) with a large pseudoaneurysm (11-cm maximum diameter) posterior to the AAA (A, Cover). Magnetic resonance imaging showed destruction of the L3 and L4 vertebral bodies by the pseudoaneurysm (B). During open surgical repair, a large defect (6 cm 4 cm) of the posterior wall of the AAA was seen, and the eroded vertebral bodies were visualized through this defect (C). Orthopedic surgeons were consulted and deemed that vertebral repair was not required. Aneurysm repair was elected, using a knitted Dacron bifurcated graft, 16 mm 8 mm in size. The patient’s right knee and thigh pain remitted postoperatively, and the patient had an uneventful postoperative course. Contained retroperitoneal rupture is a rare presentation of ruptured AAA and can present with a variety of symptoms, including femoral neuropathy. The femoral nerve arises within the psoas major and emerges from its lateral border to run between the psoas major and the iliacus behind the iliac fascia. Thus, the location of the femoral nerves makes it vulnerable to compromise in the context of retroperitoneallycontained abdominal aortic rupture and may therefore result in symptoms of femoral neuropathy. Vertebral erosion is also reported as a complication of contained retroperitoneal rupture, usually accompanied by lower back pain. In this case, lower back pain was not prominent. Clinicians should consider this rare etiology in patients with isolated lower limb neuropathy of unexplained origin.

Tetralogy of Fallot (TOF) is a congenital heart disease that is usually diagnosed and treated during infancy. Only 3% of such patients reach the age of 40 without surgery. We describe a 61-year-old woman with uncorrected TOF that was successfully treated by radical surgery. The patient presented with exertional dyspnea, insomnia, and malaise. Echocardiography and cardiac catheterization indicated a dilated, severely hypertrophic right ventricle, ventricular septal defect, an overriding aorta, and infundibular stenosis in the right ventricular outflow tract. All symptoms disappeared after full surgical correction, which remains the preferred treatment for adult TOF because it confers long-term survival and an improved quality of life.

Objective This study aimed to determine the effect and mechanisms of remote postconditioning (RPC) upon ischaemia–reperfusion injury (IRI) in the ischaemic mouse hindlimb. Design RPC is the brief application of ischaemia to remote organs immediately before reperfusion of an ischaemic target organ, and it is a novel approach to IRI attenuation. Materials and methods Right hindlimb ischaemia was induced in mice using a rubber tourniquet, the release of which initiated reperfusion. We established RPC by 5 min of ischaemia followed by 5 min of reperfusion in the left hindlimb immediately before right hindlimb reperfusion. The wet/dry ratio of skeletal muscle (degree of tissue oedema), myeloperoxidase (MPO) activity (accumulation of neutrophils), and nitroblue tetrazolium reduction (tissue necrosis) were evaluated. We also intra-peritoneally injected 8-sulphophenyltheophylline (SPT), an adenosine receptor inhibitor, in RPC mice. Results Wet/dry ratio, MPO activity and tissue necrosis were significantly lower in the RPC group than in the control group, and injection of SPT impaired the protective effect of RPC. Conclusions Our results show that RPC attenuated IRI in murine hindlimb ischaemia, possibly through endogenous adenosine receptor activation, and that RPC might serve as a promising therapeutic option for treating serious limb ischaemia.

Background: Although intravenous administration of prostaglandin E1 (PGE1) is commonly used in the treatment of peripheral arterial disease, it rapidly becomes inactivated in the lung. Whether local administration of sustained-release (SR) PGE1 enhances neovascularization in murine hindlimb ischemia was investigated. Methods and Results: Poly lactide-co-glycolide (PLGA) microspheres were the 4-week SR carrier of PGE1. C57BL/6 mice with unilateral hindlimb ischemia were randomly treated as follows: no treatment (Group N); single administration of 100 μg/kg PGE1 solution (Group L) into the ischemic muscles; daily systemic administration of PGE1 for 2 weeks at a total dose 100 μg/kg (Group S); and single administration of PGE1-100 μg/kg-loaded PLGA (Group P100) into the ischemic muscles. The blood perfusion in Group P100 was higher than in Groups N, L and S (ischemic/nonischemic blood perfusion ratio 88 ±11% vs 73 ±11% (P

A 65-year-old man who had sustained a blunt chest trauma in a traffic accident demonstrated a mass in the left hilum by chest radiography. Emergency surgery demonstrated a rupture of the left-side pericardium with herniation of the heart into the left pleural cavity along with a right ventricular rupture. The tear in the right ventricle was sutured using 4-0 polypropylene with felt and the pericardial rupture was repaired with an expanded polytetrafluoroethylene sheet. A 31-year-old man who had been crushed against a tree while skiing 5 years and 6 months earlier was diagnosed as having severe tricuspid valve regurgitation and tricuspid valve replacement was performed. Large left pericardial defect was found and repaired with an equine pericardial patch. In both cases, a bridging of phrenic nerve was found in the pericardial defect that was regarded as a traumatic rupture.

Introduction: TA-GVHD is a rare, usually fatal complication from blood transfusions wherein donor lymphocytes engraft and mount an immune response against recipient tissues. Immunocompromised hosts who are unable to recognize and destroy foreign lymphocytes are at theoretical risk of TA-GVHD, and a variety of immune incompetencies thus form the indications for cellular blood component irradiation. Much of our understanding on who is at risk of TA-GVHD as well as policies regarding who should receive irradiated components derive from case reports and small case series. We performed a systematic review of cases of TA-GVHD to refine evidence-based guidelines for the use of gamma-irradiated blood components, assess the usefulness of the Centers for Disease Control (CDC) criteria in making the diagnosis of TA-GVHD and to define the minimum details of a case of TA-GVHD that should be reported. Methods: Our systematic review, which was registered with PROSPERO, included all reported cases of TA-GVHD from 1947 until September 2013 with no restrictions on language or date. Titles and abstracts were reviewed by two independent reviewers. References were assessed for additional cases. Data collected included patient demographics, details regarding the transfusion(s), clinicolaboratory features outlined in the CDC criteria (rash, diarrhea, fever, hepatomegaly, liver dysfunction, marrow aplasia and pancytopenia), patient outcomes and results of HLA and chimerism studies. Results: After duplicates were removed, 2130 publications were available for review, with 348 cases of TA-GVHD included in the analysis. The median age was 58 years (IQR 18, 68) with 61.6% males. The most frequent underlying diagnoses were non-cardiac surgery (n=81, 23.3%), cardiac surgery (n=71, 20.4%) and hematologic malignancy (n=66, 19.0%). According to our institutional guidelines for irradiation of blood components (Massachusetts General Hospital, Sunnybrook Health Sciences Centre, The Hospital for Sick Children and University Health Network), 121 cases (34.5%) met the criteria for requiring irradiation of blood components. Among the 245 patients in whom time of symptom onset was reported, the first symptom of TA-GVHD occurred a median of 11 (IQR 8, 14) days from the implicated transfusion. Patients had an average of 3.6 symptoms and/or signs of TA-GVHD using the CDC definition, with rash being the most common finding in 80.2% of cases (Figure 1). A biopsy was performed in 67.5% of cases, with skin as the most common site in 97.0% of cases. Chimerism studies were done in 103 cases (29.7%) to confirm the diagnosis. According to the CDC case definition, 215 (62.0%) had definitive and 73 (21.0%) had probable TA-GVHD. The case imputability based on the CDC definition was definite, probable, possible and doubtful in 28.5, 2.3, 50.0 and 2.0% of cases, respectively. The implicated blood component was red blood cells in 132 cases (37.9%), whole blood in 92 cases (26.4%), and platelets in 20 cases (5.7%). The treatment for TA-GVHD was immunosuppression therapy (IST) in 48.9%, bone marrow transplant (BMT) in 2.3%, and no intervention in 46.7%. Of those treated with IST or BMT, 10.7% survived, whereas 5.6% of the untreated survived, p = 0.063. Overall, 29 patients (8.4%) survived; of these, 3 (10.3%) received BMT, 16 (55.2%) IST and 10 (31.0%) no therapy. Conclusions: To our knowledge this is the largest systematic review of reported cases of TA-GVHD. This review describes the diversity of patient characteristics and presentations of TA-GVHD. Firstly, patients at risk for TA-GVHD encompass all levels of immune integrity, and reliance on the patient's underlying diagnosis to dictate the need for irradiated blood components limits mitigation, as blood component or donor-recipient factors may be more important considerations. Secondly, the analysis of cases revealed limitations and inconsistencies in reported details, underscoring the need for consensus on reporting criteria, without which TA-GVHD case confirmation is challenging. Figure 1: Percentage of patients with the symptoms and signs of TA-GVHD according to the CDC case definition Figure 1:. Percentage of patients with the symptoms and signs of TA-GVHD according to the CDC case definition Disclosures No relevant conflicts of interest to declare.

Importance Ischemic heart disease is the leading cause of death globally. Coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) are the revascularization options for ischemic heart disease. However, the choice of the most appropriate revascularization modality is controversial in some patient subgroups. Objective To summarize the current evidence comparing the effectiveness of CABG surgery and PCI in patients with unprotected left main disease (ULMD, in which there is >50% left main coronary stenosis without protective bypass grafts), multivessel coronary artery disease (CAD), diabetes, or left ventricular dysfunction (LVD). Evidence Review A search of OvidSP MEDLINE, EMBASE, and Cochrane databases between January 2007 and June 2013, limited to randomized clinical trials (RCTs) and meta-analysis of trials and/or observational studies comparing CABG surgery with PCI was performed. Bibliographies of relevant studies were also searched. Mortality and major adverse cardiac and cerebrovascular events (MACCE, defined as all-cause mortality, myocardial infarction, stroke, and repeat revascularization) were reported wherever possible. Findings Thirteen RCTs and 5 meta-analyses were included. CABG surgery should be recommended in patients with ULMD, multivessel CAD, or LVD, if the severity of coronary disease is deemed to be complex (SYNTAX >22) due to lower cardiac events associated with CABG surgery. In cases in which coronary disease is less complex (SYNTAX ≤22) and/or the patient is a higher surgical risk, PCI should be considered. For patients with diabetes and multivessel CAD, CABG surgery should be recommended as standard therapy irrespective of the severity of coronary anatomy, given improved long-term survival and lower cardiac events (5-year MACCE, 18.7% for CABG surgery vs 26.6% for PCI; P = .005). Overall, the incidence of repeat revascularization is higher after PCI, whereas stroke is higher after CABG surgery. Current literature emphasizes the importance of a heart-team approach that should consider coronary anatomy, patient characteristics, and local expertise in revascularization options. Literature pertaining to revascularization options in LVD is scarce predominantly due to LVD being an exclusion factor in most studies. Conclusions and Relevance Both CABG surgery and PCI are reasonable options for patients with advanced CAD. Patients with diabetes generally have better outcomes with CABG surgery than PCI. In cases of ULMD, multivessel CAD, or LVD, CABG surgery should be favored in patients with complex coronary lesions and anatomy and PCI in less complicated coronary disease or deemed a high surgical risk. A heart-team approach should evaluate coronary disease complexity, patient comorbidities, patient preferences, and local expertise.

A69-year-old man with diabetes mellitus presented at our hospital with exertional chest pain. An exercise test showed a horizontal ST depression in the lateral leads. Multidetector computed tomography revealed a single coronary artery arising from the left sinus of Valsalva and an anomalous branch originating from the midportion of the left anterior descending (LAD) artery that traversed to the right side of the heart along the course of the right coronary artery (RCA). Diffuse calcification in the midportion of the LAD artery indicated stenosis in this section (Fig 1). Coronary angiography revealed severe stenosis in the ostium of the anomalous RCA and around the bifurcation of the LAD artery (Fig 2). He underwent off-pump coronary artery bypass grafting for the LAD artery and anomalous RCA. The left internal thoracic artery (LITA) was anastomosed to the LAD artery, and a saphenous vein graft (SVG) was anastomosed to the proximal portion of the anomalous RCA. The postoperative course was uneventful, and all grafts were patent (Fig 3). An anomalous RCA arising from the LAD artery is extremely rare, and few surgical interventions have been reported. Multidetector computed tomography can provide an accurate diagnosis and valuable information for preoperative planning.