Ja Hong Kuh

SRSF5: a novel marker for small-cell lung cancer and pleural metastatic cancer.

OBJECTIVES SR-splicing factors (SRSFs) play important roles in oncogenesis. However, the expression of SRSF 5-7 proteins in lung cancer (LC) is unclear, and their use in the diagnosis of pleural diseases has never been assessed. We evaluated SRSF 5-7 protein levels in LC and their diagnostic potential for cancer cells in lung and pleural effusion (PE) and, for the dysregulated SRSFs, investigated their neutralization effect on LC. MATERIALS AND METHODS SRSF 5-7 levels in lung tissue and PE cell lysate samples (n=453) were compared with the results of conventional tumor markers. Knockdown of SRSF gene expression was performed using small interfering RNAs on small-cell LC (SCLC) cell lines. RESULTS In lung tissue analysis, SRSF 5-7 levels were up-regulated in LC samples compared with non-tumoral lung tissue samples; they were markedly higher in SCLC than in adenocarcinoma or squamous cell carcinoma. SRSF5 showed the highest detection accuracy (89%) for total LC, and it was superior to that (74%) of carcinoembryonic antigen [CEA, a commonly used non-SCLC (NSCLC) marker]. Notably, the detection accuracies of the three SRSFs for SCLC were all 100% and higher than that (69%) of a pro-gastrin-releasing peptide (a well-known SCLC marker). In PE cell analysis, the detection accuracy (86%) of SRSF5 for malignant cells was highest among SRSFs and comparable to that (83%) of CEA. SRSF5 additionally detected 70% of CEA-missed non-NSCLC cases. Down-regulation of the SRSFs induced mild (SRSF5 and SRSF7) to remarkably (SRSF6) reduced cell proliferation. CONCLUSIONS Our results demonstrated the up-regulated expression of SRSF 5-7 proteins in LC with much more profound up-regulation in SCLC than in NSCLC and suggest that up-regulation of the SRSFs is related to SCLC proliferation. Moreover, we identified SRSF5 as a novel detection marker for SCLC and pleural metastatic cancer cells.

Aortic Valve Replacement Using Continuous Suture Technique in Patients with Aortic Valve Disease

Background The continuous suture (CS) technique has several advantages as a method for simple, fast, and secure aortic valve replacement (AVR). We used a simple CS technique without the use of a pledget for AVR and evaluated the surgical outcomes. Materials and Methods Between October 2007 and 2012, 123 patients with aortic valve disease underwent AVR alone (n=28) or with other concomitant cardiac procedures (n=95), such as mitral, tricuspid, or aortic surgery. The patients were divided into two groups: the interrupted suture (IS) group (n=47), in which the conventional IS technique was used, and the CS group (n=76), in which the simple CS technique was used. Results There were two hospital deaths (1.6%), which were not related to the suture technique. There were no significant differences in cardiopulmonary bypass time or aortic cross-clamp time between the two groups for AVR alone or AVR with concomitant cardiac procedures. In the IS group, two patients had prosthetic endocarditis and one patient experienced significant perivalvular leak. These patients underwent reoperations. In the CS group, there were no complications related to the surgery. Postoperatively, the two groups had similar aortic valve gradients. Conclusion The simple CS method is useful and secure for AVR in patients with aortic valve disease, and it may minimize surgical complications, as neither pledgets nor braided sutures are used.

Simultaneous relief of acute visceral and limb ischemia in complicated type B aortic dissection by axillobifemoral bypass.

FIGURE 1. Contrast-enhanced computed tomography shows acute type B dissection (white arrow), originating distal to the left subclavian artery and extending only to the mid descending thoracic aorta. A 78-year-old man with a history of aortic valve replacement and ascending aorta replacement sought treatment with severe back pain. Contrast-enhanced computed tomography revealed a Stanford type B acute aortic dissection (Figure 1). The patient was admitted to the intensive care unit, and antihypertensive drugs were administered. The next day, the patient had sharp pain in right lower extremity, pulse deficit in the right femoral artery, and abdominal pain with decreasing bowel sounds. Urgent computed tomography showed the progression of acute type B aortic dissection, which extended from the distal aortic arch to the bilateral external iliac arteries, and also demonstrated stenosis of the superior mesenteric artery and disappearance of flow in the right common iliac artery (Figure 2). We diagnosed malperfusion in acute type B dissection. The patient had became unstable and irritable. At first, we performed femorofemoral bypass; however, there was no flow in the bypass graft. Right axillobifemoral bypass grafting was therefore performed with an 8-mm ringed polytetrafluoroethylene graft tracked subcutaneously. The next day, the patient’s ischemic signs of right lower limb and abdominal pain were dramatically ameliorated, so the planned aortic fenestration and proximal stent-graft placement were cancelled. One year later, this patient is in good condition, with neither intermittent claudication nor abdominal angina. Follow-up computed tomographic angiograms at 1 and 12 months revealed the restoration of blood flow to the right iliac and mesenteric arteries with adequate aortic remodeling (Figure 3).

Predictive Factors of Sustained Sinus Rhythm and Recurrent Atrial Fibrillation after the Maze Procedure

Background We examined perioperative predictors of sustained sinus rhythm (SR) in patients undergoing the Cox maze operation and concomitant cardiac surgery for structural heart disease. Materials and Methods From October 1999 to December 2008, 90 patients with atrial fibrillation (AF) underwent the Cox maze operation and other concomitant cardiac surgery. Eighty-nine patients, all except for one postoperative death, were followed-up with serial electrocardiographic studies, 24-hour Holter monitoring tests, and regular echocardiographic studies. Results Eighty-nine patients undergoing the maze operation were divided into two groups according to the presence of SR. At the time of last follow-up (mean follow-up period, 51.0±30.8 months), 79 patients (88.8%) showed SR (SR group) and 10 patients (11.2%) had recurrent AF (AF group). Factors predictive of sustained SR were the immediate postoperative conversion to SR (odds ratio, 97.2; p=0.001) and the presence of SR at the 6th month postoperatively (odds ratio, 155.7; p=0.002). Duration of AF, mitral valve surgery, number of valves undergoing surgery, left atrial dimension, and perioperative left ventricular dimensions and ejection fractions were not predictors of postoperative maintenance of SR. Conclusion Immediate postoperative SR conversion and the presence of SR at the 6th postoperative month were independent predictors of sustained SR after the maze operation.

Myocardial Protection and Hemostasis in Aortic Root Surgery: In Resident Training

1. Nachira D, Congedo MT, Ferretti GM, Margaritora S, Bello G. High-flow nasal oxygen after lung resection: can it be helpful? (letter). Ann Thorac Surg 2016;102:1410–1. 2. Ansari BM, Hogan MP, Collier TJ, et al. A randomized controlled trial of high-flow nasal oxygen (Optiflow) as part of an enhanced recovery program after lung resection surgery. Ann Thorac Surg 2016;101:459–64. 3. Zochios V, Klein A, Jones N, et al. Rationale and design of a randomised controlled trial of high-flow nasal oxygen (Optiflow) and standard oxygen therapy in high-risk patients after cardiac surgery. J Cardiol Clin Res 2015;3:1045. 4. Gim enez-Mil a M, Klein AA, Martinez G. Design and implementation of an enhanced recovery program in thoracic surgery. J Thorac Dis 2016;8(Suppl 1):S37–45. 5. Zochios V, Klein AA, Jones N, Kriz T. Effect of high-flow nasal oxygen on pulmonary complications and outcomes after adult cardiothoracic surgery: a qualitative review. J Cardiothorac Vasc Anaes 2015 Dec 18; [Epub ahead of print], http://dx.doi. org/10.1053/j.jvca.2015.12.023.

Solitary fibrous tumor as a cause of chronic cough.

A 64-year-old man who was a nonsmoker, presented with nonproductive cough for more than 3 months and an abnormal radiologic finding (Figure 1a). His complete blood count, liver and respiratory function tests were within normal limits. On bronchoscopy, the mucosa appeared normal. Contrast-enhanced computed tomography showed a well-circumscribed hypervascular heterogeneous mass in the right lower lobe, adherent to the diaphragm peripherally (Figure 1b). An ultrasound-guided transthoracic biopsy was nondiagnostic. The patient underwent exploration by thoracotomy with a video-assisted thoracoscopic view that showed a large pyramid-shaped pleural-based mass with smooth well-circumscribed encapsulation and a prominently vascularized stalk to the right lower lung (Figure 2a, 2b). The mass was resected with concomitant wedge resection of lung parenchyma at the base of the vascularized stalk. There was no evidence of penetration of the tumor through the visceral pleura or communication with neighboring structures. The diaphragmatic surface of the mass was firmer than the other sides of the pyramidal shape. Microscopically, there were spindle or epithelial cells with a hemangiopericytoma-like vascular pattern (Figure 2c). Mitotic activity was present (3 mitoses per high-power field). These findings indicated a solitary fibrous tumor, probably derived from the visceral pleura. The postoperative course was uneventful, and the patient was doing well without mass recurrence or cough after 2 years. Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(5) 602–603 The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313519806 aan.sagepub.com

Cost-Effectiveness of Carotid Endarterectomy versus Carotid Artery Stenting for Treatment of Carotid Artery Stenosis

Background Symptomatic or asymptomatic patients with significant carotid artery stenosis (range, 70% to 99%) generally undergo either carotid artery endarterectomy (CEA) or carotid artery stenting (CAS) to prevent stroke. In this study, we evaluated the cost effectiveness of these two treatment modalities. Methods A total of 47 patients (mean age, 67.1±9.1 years; male, 87.2%) undergoing either CEA (n=28) or CAS (n=19) for the treatment of significant carotid artery stenosis were enrolled in this study. Hospitalization costs were subdivided into three parts, namely pre-procedure, procedure and resource, and post-procedure costs. Results Total hospitalization costs were similar in both groups of CEA and CAS (6,377 thousand won [TW] vs. 6,703 TW, p=0.255); however, the total cost minus the pre-procedure cost was higher in the CAS group than in the CEA group (4,948 TW vs. 5,941 TW, p<0.0001). The pre-procedure cost of the CEA group was higher than that of the CAS group (1,429 TW vs. 762 TW, p<0.0001). However, the procedure and resource cost was higher in the CAS group because the resource cost was approximately three times higher in the CAS group than in the CEA group. The post-procedure cost was higher in the CEA group because hospital stays were approximately two times longer. Conclusion The total hospitalization cost was not different between the CEA and the CAS groups. The pre-procedure cost was high in the CEA group, but the cost from procedure onset to discharge, including the resource cost, was significantly lower in this group.

Treatment of Atrial Fibrillation in Elderly Patients with the Cox Maze Procedure Concurrently with Other Cardiac Operations

Background In elderly patients who have atrial fibrillation (AF), surgical ablation of the arrhythmia during cardiac surgery may be challenging. Despite the reported advantages of ablating AF with the Cox maze procedure (CMP), the addition of the CMP may complicate other cardiac operations. We evaluated the effect of the CMP in elderly patients concurrent with other cardiac operations. Methods From October 2007 to December 2015, we enrolled 27 patients aged >70 years who had AF and who underwent the CMP concurrently with other cardiac operations. The mean preoperative additive European System for Cardiac Operative Risk Evaluation score was 8±11 (high risk). Results Only 1 hospital death occurred (4%). The Kaplan-Meier method showed a high 5-year cumulative survival rate (92%). At mean follow-up of 51 months, 23 patients (89%) had sinus rhythm conversion. The postoperative left atrial dimensions did not significantly differ between the 8 patients who had reduction plasty for giant left atrium (53.4±7.5 cm) and the 19 patients who did not have reduction plasty (48.7±5.7 cm). Conclusion In patients aged >70 years, concurrent CMP may be associated with a high rate of sinus rhythm conversion without increased surgical risk, despite the added complexity of the main cardiac procedure.

Surgical Lessons from the Repair of Recurrent Tricuspid Regurgitation after DeVega Annuloplasty

A 67-year-old man had undergone DeVega annuloplasty (with use of monofilament polypropylene suture) and mitral valve replacement 3 years before he presented at our hospital. Transesophageal echocardiograms showed paravalvular leakage of the mitral prosthesis, moderate-to-severe tricuspid regurgitation (TR) associated with annular dilation (diameter, 4.2 cm) (Fig. 1A), an echodense streak at the tricuspid annular level in diastole (Fig. 1B), and a pulmonary artery systolic pressure of 26 mmHg. During repair of the paravalvular mitral leak and the TR, one strand of tricuspid annuloplasty suture was found tethered across the valve aperture consequent to atrial tissue laceration; another suture strand was superficially buried in the annulus (Fig. 2). The TR was repaired with use of a no. 28 Edwards MC3 Tricuspid Annuloplasty Ring (Edwards Lifesciences Corporation; Irvine, Calif ). Images in Cardiovascular Medicine

Haemodynamic improvement of older, previously replaced mechanical mitral valves by removal of the subvalvular pannus in redo cardiac surgery

Patients requiring redo cardiac surgery for diseased heart valves other than mitral valves may show increased pressure gradients and reduced valve areas of previously placed mechanical mitral valves due to subvalvular pannus formation. We treated four women who had mechanical mitral valves inserted greater than or equal to 20 years earlier and who presented with circular pannus that protruded into the lower margin of the valve ring but did not impede leaflet motion. Pannus removal improved the haemodynamic function of the mitral valve.