Masahiro Daimon

Immunoglobulin G4―related coronary periarteritis in a patient presenting with myocardial ischemia

Recent studies suggest that the cardiovascular system might be a possible target of immunoglobulin G4-related disease. Here we present a 66-year-old man who was admitted to our hospital because of chest symptoms suggestive of acute coronary syndrome. Besides luminal narrowing of the coronary arteries, marked periarterial thickening around the coronary artery was observed by computed tomography coronary angiography. Serum immunoglobulin G4 levels of this patient were elevated (564 mg/dL). The patient underwent coronary bypass surgery. After incision of the pericardium, a glittery white-yellowish, elastic-hard periarterial mass surrounding the left circumflex artery could be seen. Histologic analysis of the biopsy specimen showed the formation of lymphoid follicles and the presence of immunoglobulin G4-positive plasma cells; therefore, the diagnosis was immunoglobulin G4-related coronary periarteritis accompanied by physiologically significant myocardial ischemia.

IgG4-positive cell infiltration in various cardiovascular disorders - results from histopathological analysis of surgical samples

BackgroundThe diagnosis of Immunoglobulin G4 (IgG4)-related disease (IgG4-RD), in general, depends on serum IgG4 concentrations and histopathological findings; therefore, diagnosis of IgG4-RD in cardiovascular organs/tissues is often difficult owing to the risk of tissue sampling.MethodsPrevalence of IgG4-positive lymphoplasmacytic infiltration in 103 consecutive cardiovascular surgical samples from 98 patients with various cardiovascular diseases was analyzed immunohistochemically.ResultsThe diagnoses of the enrolled patients included aortic aneurysm (abdominal, n = 8; thoracic, n = 9); aortic dissection (n = 20); aortic stenosis (n = 24), aortic regurgitation (n = 10), and mitral stenosis/regurgitation (n = 17). In total, 10 (9.7%) of the 103 specimens showed IgG4-positive cell infiltration with various intensities; five of these were aortic valve specimens from aortic stenosis, and IgG4-positive cell infiltration was present at >10 /HPF in three of them. In one aortic wall sample from an abdominal aortic aneurysm, various histopathological features of IgG4-RD, such as IgG4-positive cell infiltration, obliterating phlebitis, and storiform fibrosis, were observed.ConclusionsIgG4-positive cell infiltration was observed in 9.7% of the surgical cardiovascular specimens, mainly in the aortic valve from aortic stenosis and in the aortic wall from aortic aneurysm. Whether IgG4-positive cell infiltration has pathophysiological importance in the development or progression of cardiovascular diseases should be investigated in future studies.

Minimizing Cerebral Embolism in Resection of Distal Aortic Arch Aneurysm Through a Left Thoracotomy

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.

Aneurysm of a right-sided descending aorta with a normal left-sided aortic arch.

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.

Takayasu Arteritis and Ulcerative Cutaneous Sarcoidosis

A 67-year-old woman was referred to our hospital due to a refractory lower extremity ulcer. Occlusion of the bilateral superficial femoral arteries and a difference (>50 mmHg) in blood pressure between the bilateral upper limbs were noted. In addition to occlusion of the left subclavian artery and stenosis at the ostium of the right coronary artery, these findings led to a diagnosis of Takayasu arteritis. Furthermore, a biopsy of the ulcerated skin lesion localized on the fibular surface showed a non-caseating cutaneous granulomatous lesion resulting in the diagnosis of cutaneous sarcoidosis. The simultaneous occurrence of cutaneous sarcoidosis and Takayasu arteritis, albeit rare, should not be overlooked.

A modified multi-patch technique for double-layered repair of ischemic posterior ventricular septal rupture

BackgroundThe rupture of the posterior ventricular septum after acute inferior myocardial infarction is more challenging to repair than ruptures in other sites since it is less accessible and anatomically restricted. We described a modification of Daggett’s original technique of multi-patch repair of ruptured posterior septum.Case presentationThe technique was employed in the operation of a 67-year-old male who presented with severe heart failure at the 10th day after he developed inferior myocardial infarction. His ventricular septum had ruptured at the level between the posteromedial papillary muscle and the mitral annulus.A large endoventricular patch covered separately over the locally patched septal defect and the ventriculotomy defect which was going to be roofed eventually with an external patch. Both defects were then individually closed in double layers, holding a single continuous patch in common. The common use of a single patch expedited multilayered closure of the left ventricular defects and could minimize geometric remodeling of the covered area. The patches on both the endocardial and the epicardial sides avoided potentially fatal bleeding from the ventriculotomy site. The transmural mattress sutures incorporating ventriculotomy patches required minimal bites toward the posteromedial papillary muscle and mitral annulus, thereby preserving the mitral valve function.ConclusionsThus, the technique enhances the advantage of the left ventriculotomy in the repair of posterior septal rupture and avoids ventriculotomy-related morbidity.

Repair of a Kommerell's diverticulum with an absent left subclavian artery and a right aortic arch

Kommerells diverticulum (KD) may be repaired on or off cardiopulmonary bypass (CPB) using an open or endovascular technique. We present images of the repair of a KD associated with a right aortic arch (RAA) and an absent left subclavian artery (LSCA). A 69-year-old male with prostate cancer was referred for evaluation of an abnormal surveillance chest X-ray (Figure 1). A computed tomography scan revealed a 5.0-cm KD with a RAA and an absent LSCA (Figure 2). Three-dimensional reconstruction revealed a small collateral vessel originating from the 5th intercostal artery to the stump of the takeoff of the LSCA (Figure 2C), with reversal of flow from the left vertebral artery to the LSCA on ultrasound. The left brachial artery pressure was 10mmHg lower than on the right. The surgical repair was performed via a right posterolateral thoracotomy through the fourth interspace. CPB was established with an arterial cannula in the ascending aorta and a venous cannula in the right atrium. The patient was cooled to 24°C and clamps were applied between the right common carotid and right subclavian arteries (RSCA) and on the proximal RSCA (Figures 3A and 3B). The aneurysmal KD and proximal descending aorta was opened and the origin of the collateral artery replacing the LSCA was closed with interrupted pledgeted sutures (Figure 3C). The descending aorta was then reconstructed with a #24 Dacron interposition graft (Japan Lifeline Inc., Tokyo, Japan) (Figure 3D). The descending aortic clamp time was 28min. Following aortic unclamping, the heart was defibrillated, and the patient was weaned off CPB without any difficulty. The patient tolerated the procedure well and had an uncomplicated post-operative course. There was no change in the left brachial artery pressure 7 months following surgery.

A Case of Aortic Stenosis with Serum IgG4 Elevation, and IgG4-Positive Plasmacytic Infiltration in the Aortic Valve, Epicardium, and Aortic Adventitia

A 74-year-old man was admitted for preoperative screening of aortic stenosis. Five months before this admission, he was found to have elevated serum immunoglobulin G4 (IgG4; 2,010 mg/dL). Computed tomography (CT) showed a soft tissue mass surrounding the abdominal aorta, suggestive of IgG4-related periaortitis. CT coronary angiography showed perivascular thickening of the right coronary artery, and subsequent coronary angiography showed a multi-vessel disease. The patient underwent aortic valve replacement and coronary bypass surgery. Immunohistochemical analysis showed IgG4-positive plasmacytic infiltration in specimens from the aortic valve, epicardium, and aortic adventitia, suggestive of the possible role of IgG4-related immune inflammation for the pathogenesis.

Pseudoaneurysm of the external iliac artery is a rare late complication after total hip arthroplasty

Vascular injury as a delayed complication of total hip arthroplasty (THA) is rare. We present a case of pseudoaneurysm of the external iliac artery due to chronic irritation from a prominent bone spicule occurring 2 years after revision THA. We successfully managed the patient with open repair, and there has been no sign of recurrence in the 2 years since the previous surgery. This report suggests that patients who have undergone THA should be followed up carefully and assessed for vascular injuries even after a substantial time.

Repetitive complications after prosthetic graft for inflammatory aortic aneurysm

The presence of retroperitoneal fibrosis after an aortic graft replacement is a marker of poor prognosis following aortic graft replacement. Herein we report the case of a 39-year-old man with retroperitoneal fibrosis that had been causing ureteral obstruction. The man had undergone repeated aortic graft replacement due to bacteremia and aortic graft–small intestinal fistula that occurred 4 years after initial aortic grafting for an inflammatory aortic aneurysm. The patient was discharged after 4 weeks of intravenous antibiotic therapy following the latest aortic graft replacement.