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A 50-year-old man who required aortic valve replacement (AVR) 3 times for severe paravalvular leakage (PVL) was diagnosed with a recurrence of severe PVL. Since the PVL recurred each time because of prosthetic valve detachment from the annulus, a fourth AVR was performed using a self-expanding sutureless valve. Postoperative echocardiography showed no significant PVL. The patient was discharged without any complications and returned to normal work soon after. In cases such as our patient, sutureless AVR could be a powerful alternative to conventional AVR.

Highlights • We performed a hybrid TEVAR for concomitant anastomotic pseudoaneurysm and CoA. • TEVAR for concomitant pseudoaneurysm and native CoA is feasible and less invasive. • TEVAR can be an alternative option for young patients who have to resume work early after surgery., Introduction Anastomotic pseudoaneurysm is one of the most common but catastrophic complications in coarctation of the aorta (CoA); this is equally true even if the initial surgery is not directly related to the coarctation. Redo open heart surgery is usually required for the pseudoaneurysm; however, redo surgery remains challenging with high morbidity and mortality rates. Presentation of case A 38-year-old woman with CoA, who had undergone left subclavian artery (LSCA) to descending aorta bypass 21 years prior, was referred to us for the treatment of distal anastomotic pseudoaneurysm. Zone 2 thoracic endovascular aortic repair (TEVAR) with LSCA debranching was performed to exclude the distal anastomotic pseudoaneurysm and expand the CoA using a stent graft. The patient completely recovered and resumed work without delay. Discussion In patients who require surgical treatment for both pseudoaneurysm and CoA, hybrid TEVAR can be an alternative surgical option instead of conventional open repair. Conclusion TEVAR for concomitant pseudoaneurysm and native CoA is feasible and less invasive, especially for young patients who have to resume work early after surgery.

Introduction We describe the successful treatment of a patient with extended-aortic prosthetic graft infection (PGI) by surgery limited to the infected lesion based on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) findings. Presentation of case A 54-year-old man, who had undergone three graft replacements (GRs) for extended-thoracic aortic aneurysms, was diagnosed with PGI complicated by an aorto-esophageal fistula. On the basis of 18F-FDG PET/CT findings, we performed a redo total arch replacement, preserving the other prosthesis where abnormal FDG uptake was not detected. All the resected tissues were positive for gram positive coccus. There were no signs of infection recurrence at 2 years postoperatively. Discussion Since activated inflammatory cells such as macrophages uptake FDG, FDG-PET/CT clarifies the localization of the infected prosthesis precisely. Conclusion Surgery localized to the infected sites detected by FDG-PET/CT can be an effective option for PGI in cases with previous multiple GRs.

Introduction and importance: For treatment of prosthetic valve endocarditis (PVE), redo-aortic valve replacement (AVR) is usually required. However, the recurrence of PVE continues to be a serious problem that needs a solution. Case presentation An 83-year-old woman who had undergone AVR for aortic infective endocarditis 12 years ago was diagnosed with PVE complicated with acute cerebral infarction. Urgent redo-AVR was performed. After complete removal of the prosthesis, Perceval S valve was implanted successfully. There were no postoperative neurological deteriorations, and the echocardiogram showed no recurrence of PVE. Clinical discussion Theoretically, the fewer prostheses left in the heart, the lower the risk of PVE recurrence. Conclusion In patients with PVE, redo-AVR using the Perceval valve may be a suitable option since Perceval reduces the prosthesis in the heart compared with conventional redo-AVR., Highlights • We performed a redo-aortic valve replacement (AVR) using the Perceval valve. • The patient had prosthetic valve endocarditis (PVE) and acute cerebral infarction. • Postoperative thrombocytopenia did not lead to any cerebral complications in this case. • Perceval reduces the prosthesis in the heart compared with conventional redo-AVR. • Redo-AVR using Perceval will be beneficial in controlling recurrence of PVE.

Highlights • Optimal timing of surgical treatment for infective endocarditis (IE) complicated by intracranial hemorrhage remains controversial. • We believe that emergency surgery in active infective endocarditis patients with intracranial hemorrhage is justified if there are multiple indications for emergency surgery and the intracranial hemorrhage is small. • Further evaluation is warranted regarding the risk of subsequent hemorrhage in patients with intracranial hemorrhage who require emergency valve surgery., Introduction Optimal timing of surgical treatment for infective endocarditis (IE) complicated by intracranial hemorrhage remains controversial. Presentation of case A 43-year-old man with IE received appropriate antibiotic therapy but had recurrence of cerebral infarction and intracranial hemorrhage (ICH). Emergency valve surgery was performed 2 days after ICH onset because of heart failure and recurrence of cerebral complications. Postoperatively, he showed no neurologic symptoms; neuroimaging showed no enlargement of ICH. Discussion Postoperative risk of neurologic deterioration may be relatively lower than previously thought in patients with IE who undergo surgery within 1 month after ICH onset. Conclusions Emergency surgery in patients with ICH is justified in cases of multiple indications for such small ICH. Further evaluation regarding the risk of subsequent hemorrhage in patients with ICH who require emergency valve surgery is warranted.

Objectives High-mobility group box 1 protein (HMGB1) fragment enhances bone marrow-derived mesenchymal stem cell (BM-MSC) recruitment to damaged tissue to promote tissue regeneration. This study aimed to evaluate whether systemic injection of HMGB1 fragment could promote tissue repair in a rat model of myocardial infarction (MI). Methods HMGB1 (n = 14) or phosphate buffered saline (n = 12, control) was administered to MI rats for 4 days. Cardiac performance and left ventricular remodeling were evaluated using ultrasonography and immunostaining. BM-MSC recruitment to damaged tissue in green fluorescent protein-bone marrow transplantation (GFP-BMT) models was evaluated using immunostaining. Results At four weeks post-treatment, the left ventricular ejection fraction was significantly improved in the HMGB1 group compared to that in the control. Interstitial fibrosis and cardiomyocyte hypertrophy were also significantly attenuated in the HMGB1 group compared to the control. In the peri-infarction area, VEGF-A mRNA expression was significantly higher and TGFβ expression was significantly attenuated in the HMGB1 group than in the control. In GFP-BMT rats, GFP+/PDGFRα+ cells were significantly mobilized to the peri-infarction area in the HMGB1 group compared to that in the control, leading to the formation of new vasculature. In addition, intravital imaging revealed that more GFP+/PDGFRα+ cells were recruited to the peri-infarction area in the HMGB1 group than in the control 12 h after treatment. Conclusions Systemic administration of HMGB1 induced angiogenesis and reduced fibrosis by recruiting PDGFRα+ mesenchymal cells from the bone marrow, suggesting that HMGB1 administration might be a new therapeutic approach for heart failure after MI.

Background High-mobility group box 1 protein (HMGB1) reportedly enhances CXCR4-positive bone marrow-derived mesenchymal stem cell (BM-MSC) recruitment to damaged tissue to promote tissue regeneration. Purpose Our aim of this study is to evaluate whether systemic administration of HMGB1 might promote tissue repair in a rat myocardial infarction (MI) model. Methods We prepared 26 MI model rats with high ligation of the left coronary artery. Two weeks later, HMGB1 (3 mg/kg/day) or phosphate-buffered saline (control: 3 mL/kg/day) was administered for 4 days via femoral vein. Cardiac performance was evaluated by ultrasonography, left ventricular (LV) remodeling via immunostaining. We then used immunostaining to examine MSC recruitment to damaged tissue in green fluorescent protein bone marrow transplantation (GFP-BMT) model rats, and also performed intravital imaging using two-photon microscopy to visualize BM-cells recruitment in real time. Results Compared with control rats, there was a significant improvement in the left ventricular ejection fraction of the HMGB1 group (HMGB1 vs. control: 48.6% ± 5.5% vs. 33.6% ± 5.4%; p Conclusions Systemic administration of HMGB1 mobilized BM-MSCs to the damaged myocardium via the SDF-1/CXCR4 signaling complex. Those BM-MSCs might migrate to extracellular matrix in the border zone via the gap of each endothelial cell, leading to induction of angiogenesis and reduced fibrosis. Acknowledgement/Funding None

OBJECTIVES The risk of spinal cord injury after thoraco-abdominal aortic aneurysm repair increases when the segmental arteries (SAs) in the critical segment are sacrificed. Such critical SAs cannot be reconstructed when performing thoracic endovascular aortic repair (TEVAR). We aimed to elucidate extrathoracic collaterals to the critical SAs (T9–L1) that develop after TEVAR. METHODS Between 2006 and 2018, the critical SAs (T9–L1) of 38 patients were sacrificed during TEVAR. Nineteen of these patients who underwent multidetector row computed tomography 6 months after surgery were included (mean age 60 ± 13 years; 10 male; Crawford extent II:III, 14:5). We retrospectively assessed extrathoracic collaterals to the sacrificed critical SAs. RESULTS Ninety-four collaterals to the critical SAs were observed, originating from the subclavian (26/94), external iliac (50/94) and internal iliac (18/94) arteries. Twenty-five of the 26 (96%) collaterals from the subclavian artery were from its lateral descending branch, and 19 of the 26 (73%) collaterals fed into T9. Forty-three of the 50 (86%) collaterals from the external iliac artery were from its lateral ascending branch, and 25 of the 50 (50%) collaterals communicated with T11. Patients with a history of left thoracotomy (no collaterals in 6 patients) had fewer collaterals via the lateral descending branch of the left subclavian artery in comparison with the patients without (10 collaterals in 13 patients) (P = 0.009). CONCLUSIONS After critical SAs were sacrificed, extrathoracic collaterals developed with certain regularity. Previous left thoracotomy could influence the development of extrathoracic collaterals from the left subclavian artery.

Highlights • Radical surgical treatment for prosthetic graft infections is still challenging. • Especially so for patients with extended-aortic prosthetic graft infection. • Redo total arch replacement while preserving prostheses with no abnormal FDG uptake. • All the resected tissues were positive for methicillin-resistant Staphylococcus epidermidis. • No signs of infection recurrence at 2 years postoperatively., Introduction We describe the successful treatment of a patient with extended-aortic prosthetic graft infection (PGI) by surgery limited to the infected lesion based on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) findings. Presentation of case A 54-year-old man, who had undergone three graft replacements (GRs) for extended-thoracic aortic aneurysms, was diagnosed with PGI complicated by an aorto-esophageal fistula. On the basis of 18F-FDG PET/CT findings, we performed a redo total arch replacement, preserving the other prosthesis where abnormal FDG uptake was not detected. All the resected tissues were positive for gram positive coccus. There were no signs of infection recurrence at 2 years postoperatively. Discussion Since activated inflammatory cells such as macrophages uptake FDG, FDG-PET/CT clarifies the localization of the infected prosthesis precisely. Conclusion Surgery localized to the infected sites detected by FDG-PET/CT can be an effective option for PGI in cases with previous multiple GRs.

Objectives Optimal methods to quantitatively evaluate the blood flow in each cerebral artery after zone 1-2 thoracic endovascular aortic repair (TEVAR) remain unknown. Our objective was to evaluate the differences between preoperative and postoperative cerebral artery blood flows after zone 1-2 debranching TEVAR (dTEVAR). Methods Between January 2016 and August 2018, a prospective analysis of the blood flow in both the internal carotid artery and the vertebral artery in 16 patients before and after zone 1-2 dTEVAR was conducted. Zone 1 dTEVAR with right axillary artery-left common carotid artery-left axillary artery (RAxA-LCCA-LAxA) bypass was performed on 7 patients. Zone 2 dTEVAR was performed on 9 patients: 4 underwent RAxA-LAxA bypass and 5 underwent LCCA-LAxA bypass. Quantitative magnetic resonance angiography was performed before and after zone 1-2 dTEVAR. Results Total intracranial blood flow was preserved postoperatively [The median (interquartile range) preoperatively vs postoperatively: 621 (549-686) vs 638 (539-703) ml/min, not significant]. The anterior [469 (400-504) vs 475 (404-510) ml/min, not significant] and posterior cerebral blood flows [157 (121-199) vs 163 (123-210) ml/min, not significant] were also maintained postoperatively. In the 3 debranching procedures, the postoperative anterior and posterior cerebral blood flows were maintained at rates similar to preoperative rates, with the proportion of anterior and posterior cerebral circulations reaching almost 75% and 25%, respectively. No significant differences between preoperative and postoperative distributions of internal carotid artery blood flows were observed. Regarding vertebral artery blood flows, the distribution of blood flow through the left vertebral artery was significantly lower postoperatively than preoperatively; however, the postoperative right vertebral artery blood flow distribution significantly increased compared with the preoperative flow. Conclusions In zone 1-2 dTEVAR, total intracranial blood flow was preserved postoperatively, and the postoperative anterior and posterior cerebral circulations were maintained at rates similar to their preoperative rates.

Objectives Silent cerebral infarction is the most common brain injury incidentally detected on imaging and can be associated with increased risks of future stroke and cognitive decline. However, the incidence and risk factors of silent cerebral infarction after thoracic endovascular aortic repair (TEVAR) for aortic arch pathologies remain unclear. This study aimed to examine silent cerebral infarction following TEVAR using diffusion-weighted (DW) magnetic resonance imaging (MRI). Methods Nineteen patients (16 men, mean age 73.3 years) who underwent elective debranching TEVAR (zone 0/1/2 = 3/8/8) were included. Perioperative brain injury was assessed via cerebral DW-MRI before and after the procedure. The atheroma ratio was calculated from preoperative computed tomography images, and we examined the association between the atheroma ratio and development of new postoperative DW-MRI lesions. Results Technical success was achieved in all patients, and no patient died within 30 days postoperatively. Postoperative DW-MRI detected a total of 24 new lesions in 5 (26%) patients (1-9 lesions per patient): 4 (21%) patients with silent cerebral infarction and 1 (5%) patient with clinical stroke. The atheroma ratio of the aortic arch (23.8 ± 2.7% vs 18.3 ± 3.9%; P = 0.023), especially at the proximal landing zone (19.5 ± 2.8% vs 14.7 ± 2.7%; P = 0.014), was significantly higher in patients with new postoperative DW-MRI lesions than that in patients without. Conclusions The incidence of silent cerebral infarction following TEVAR with supra-aortic debranching for aortic arch pathologies was 21%, and the severity of atheromatous change in the aortic arch, especially in the proximal landing zone, was positively associated with the development of silent cerebral infarction.

Recent advances in intravital microscopy have provided insight into dynamic biological events at the cellular level in both healthy and pathological tissue. However, real-time in vivo cellular imaging of the beating heart has not been fully established, mainly due to the difficulty of obtaining clear images through cycles of cardiac and respiratory motion. Here we report the successful recording of clear in vivo moving images of the beating rat heart by two-photon microscopy facilitated by cardiothoracic surgery and a novel cardiac stabiliser. Subcellular dynamics of the major cardiac components including the myocardium and its subcellular structures (i.e., nuclei and myofibrils) and mitochondrial distribution in cardiac myocytes were visualised for 4–5 h in green fluorescent protein-expressing transgenic Lewis rats at 15 frames/s. We also observed ischaemia/reperfusion (I/R) injury-induced suppression of the contraction/relaxation cycle and the consequent increase in cell permeability and leukocyte accumulation in cardiac tissue. I/R injury was induced in other transgenic mouse lines to further clarify the biological events in cardiac tissue. This imaging system can serve as an alternative modality for real time monitoring in animal models and cardiological drug screening, and can contribute to the development of more effective treatments for cardiac diseases.

ObjectivesWe hypothesized that systemic administration of high-mobility group box 1 fragment attenuates the progression of myocardial fibrosis and cardiac dysfunction in a hamster model of dilated cardiomyopathy by recruiting bone marrow mesenchymal stem cells thus causing enhancement of a self-regeneration system.MethodsTwenty-week-old J2N-k hamsters, which are δ-sarcoglycan-deficient, were treated with systemic injection of high-mobility group box 1 fragment (HMGB1, n=15) or phosphate buffered saline (control, n=11). Echocardiography for left ventricular function, cardiac histology, and molecular biology were analyzed. The life-prolonging effect was assessed separately using the HMGB1 and control groups, in addition to a monthly HMGB1 group which received monthly systemic injections of high-mobility group box 1 fragment, 3 times (HMGB1, n=11, control, n=9, monthly HMGB1, n=9).ResultsThe HMGB1 group showed improved left ventricular ejection fraction, reduced myocardial fibrosis, and increased capillary density. The number of platelet-derived growth factor receptor-alpha and CD106 positive mesenchymal stem cells detected in the myocardium was significantly increased, and intra-myocardial expression of tumor necrosis factor α stimulating gene 6, hepatic growth factor, and vascular endothelial growth factor were significantly upregulated after high-mobility group box 1 fragment administration. Improved survival was observed in the monthly HMGB1 group compared with the control group.ConclusionsSystemic high-mobility group box 1 fragment administration attenuates the progression of left ventricular remodeling in a hamster model of dilated cardiomyopathy by enhanced homing of bone marrow mesenchymal stem cells into damaged myocardium, suggesting that high-mobility group box 1 fragment could be a new treatment for dilated cardiomyopathy.

Pseudoaneurysm at the suture line is one of the most common complications in aortic surgery for Takayasu arteritis (TA) and is associated with a high mortality rate. A 52-year-old man with TA, who previously underwent the Bentall procedure and 2 redo surgeries for coronary artery obstruction and a pseudoaneurysm of a coronary button, was diagnosed with an anastomotic pseudoaneurysm in the ascending aorta. Hybrid zone 0 debranching thoracic endovascular aortic repair was performed, and the patient was discharged uneventfully on postoperative day 8.