Masakazu Matsuyama

Inhibition of Development of Abdominal Aortic Aneurysm by Glycolysis Restriction

Objective—The mechanisms underlying abdominal aortic aneurysm development remain unknown. We hypothesized that acceleration of glucose metabolism with the upregulation of glucose transporters is associated with abdominal aortic aneurysm development. Methods and Results—Enhanced accumulation of the modified glucose analogue 18 fluoro-deoxyglucose by positron emission tomography imaging in the human abdominal aortic aneurysm was associated with protein expressions of glucose transporters-1 and -3, assessed by Western blot. The magnitude of glucose transporter-3 expression was correlated with zymographic matrix metalloproteinase-9 activity. Intraperitoneal administration of glycolysis inhibitor with 2-deoxyglucose significantly attenuated the dilatation of abdominal aorta induced by periaortic application of CaCl2 in C57BL/6J male mice or reduced the aneurysmal formation in angiotensin II-infused apolipoprotein E knockout male mice. In monocytic cell line induced by phorbol 12-myristate 13-acetate or ex vivo culture obtained from human aneurysmal tissues, 2-deoxyglucose abrogated the matrix metalloproteinase-9 activity and interleukin-6 expression in these cells/tissues. Moreover, 2-deoxyglucose attenuated the survival/proliferation of monocytes and the adherence of them to vascular endothelial cells. Conclusion—This study suggests that the enhanced glycolytic activity in aortic wall contributes to the pathogenesis of aneurysm development. In addition, pharmacological intervention in glycolytic activity might be a potential therapeutic target for the disorder.

Inflammatory abdominal aortic aneurysm: report of seven cases.

We reviewed 575 cases of abdominal aortic aneurysm (AAA) repair performed in our institution from 1979 to 2010. In this group, 7 (1.2%) patients (mean age, 72.6 years) had evidence of inflammatory AAA (IAAA). Mean aneurysmal diameter was 70.4 mm as measured on CT, and the mantle sign was present in all cases. They were male smokers. Two patients had hydronephrosis, and required a ureteral stent before surgery. All patients underwent laparotomy, and no perioperative deaths occured. We suggest that operative technique should be modified to avoid excessive dissection on both the proximal and distal sides of the IAAA.

Spontaneous left subclavian artery dissection with concurrent thrombosis and embolic occlusion of the lower limbs: report of a case.

A subclavian artery dissection (SAD) is usually associated with coexisting aortic disease, and spontaneous SAD is extremely rare. This report presents the case of a spontaneous SAD patient who developed atypical clinical symptoms. A 41-year-old woman presented with bilateral ischemia of her lower limbs. An urgent bilateral femoral thrombo-embolectomy was performed using a balloon catheter. Postoperative enhanced computed tomography (CT) demonstrated a localized thrombus in the left subclavian artery extending toward the descending thoracic aorta, and a follow-up CT angiogram obtained 3 months later revealed left SAD and complete resolution of the thrombus. The patient was anticoagulated with warfarin in addition to antiplatelet drugs after the balloon catheter thromboembolectomy. This is the first report of lower limb ischemia caused by an embolism from a mural thrombus of the descending thoracic aorta extending from spontaneous SAD.

Open surgery or stent repair for descending aortic diseases: Results and risk factor analysis

Objectives. Less invasive stent graft (SG) repair was compared with open surgery for patients with descending thoracic aortic diseases. Design. Thirty six patients undergoing SG repair (SG group) were matched for age, sex, location and pathology of aortic disease with a 36-patient surgical cohort (OS group), and retrospective matched case-control study was performed with respect to outcomes and risk factors for adverse outcomes. Results. Mortality rate was 5.6% in OS group and none in SG group (p=0.4930), and there was no significant difference in stroke and paraplegia rates between two groups. A higher prevalence of secondary procedures due to endoleak was seen in the patients of SG group (p=0.0113). Perioperative hypotension was an independent risk factor for in-hospital mortality (p=0.0071, odds ratio=34) and preoperative renal dysfunction was independent risk factor for paraplegia (p=0.0076, odds ratio=17.6). Conclusions. Although the importance of patient selection is emphasized to prevent endoleak, mortality rate was low in patients who underwent SG repair. SG repair is a promising alternative technique to open surgery for thoracic aortic diseases.

Two Dehiscences of the Aortic Valve Commissure and Cusp with Progressive Acute Aortic Regurgitation

A 54-year-old female with acute heart failure due to aortic regurgitation (AR) was admitted to our hospital. Following admission, her condition worsened progressively; thus, surgery was performed prematurely. During surgery, two dehiscences were visualized in the aortic valve commissure between the right and left cusps and the upper part of the left coronary artery ostium. However we scheduled aortic valve replacement (AVR) at first, we made the shift to perform the aortic root replacement for reinforcement of the aortic wall around the left coronary artery ostium. We describe a rare case of two dehiscences at the aortic root, which is the first report.

Long-Term Results of Endovascular Repair for Distal Arch and Descending Thoracic Aortic Aneurysms Treated by Custom-Made Endografts: Usefulness of Fenestrated Endografts

OBJECTIVE We evaluated early and long-term results of atherosclerotic aneurysm repair with custom-made endografts. MATERIALS AND METHODS Eighty-one consecutive patients underwent thoracic endovascular aortic repair with custom-made endografts. Fenestrated grafts were used in 37 patients (45.7%) to maintain blood flow of the neck and a landing zone for as long as possible for distal arch or proximal descending aneurysms. The rates of perioperative mortality, stroke, paraplegia, and primary endoleaks were assessed to evaluate in-hospital safety. The rates of endoleak development, survival, and freedom from aortic-related death were assessed to evaluate long-term efficiency. RESULTS Twenty-four patients (29.6%) underwent urgent operations, and 38 (46.9%) underwent distal arch or proximal descending aortic aneurysm repair. There was one case (1.2%) of in-hospital mortality and no cases of stroke. Permanent spinal injury occurred in one patient (1.2%). Early and late endoleaks occurred in one and 16 patients, respectively. The actuarial survival rates were 88.9%, 64.9%, and 51.7% at 1, 5, and 10 years, respectively. The actuarial rates of freedom from endoleaks were 90.1%, 81.3%, and 68.6% at 1, 5, and 10 years, respectively. CONCLUSION Early results of custom-made endografts were excellent, and fenestrated endografts were safe for distal arch and proximal descending aortic aneurysms.

Perforated mitral valve aneurysm diagnosed 3 years after etiology-unknown iliopsoas muscle abscess: illustrative case of ‘self-attack’ endocarditis of the mitral valve

Transthoracic echocardiography (TTE) is a useful diagnostic tool as a first-line screening examination for infective endocarditis [1]. However, the critical cardiac disease is often overlooked as it may be hidden behind other systemic symptoms. A 70-year-old female with severe mitral regurgitation (MR) presented with congestive heart failure. TTE revealed mitral valve (MV) prolapse with severe eccentric MR which was observed as bidirectional color Doppler signal. Left ventricular ejection fraction was 70%. MR volume was 62 ml by proximal isovelocity surface area method. Transesophageal echocardiography (TEE) clearly revealed a perforated aneurysm in the posterior middle scallop with severe MR through the aneurysm (Fig. 1a). Eccentric MR originated separately from the prolapsed lateral scallop (P1), hitting the surface of the middle scallop (P2) (Fig. 1b). The patient had a history of etiologyunknown iliopsoas muscle abscess with methicillin-resistant Staphylococcus aureus infection 3 years before her admission (Fig. 1d), which had been treated successfully using antibiotics for 2 months. Screening TTE had been performed at that time, which revealed mild to moderate MR but no apparent findings of vegetation. TEE had not been performed throughout her previous hospitalization. In the present case, we speculated that the patient originally had lateral scallop prolapse due to ruptured chordae and had then acquired a bacterial infection due to dental caries and a root abscess. An MV aneurysm in P2 might have been caused by an eccentric jet from P1. Although the previous endocarditis had not been clinically diagnosed, antibiotic treatment for the iliopsoas muscle abscess would have been effective both in the abscess and valvular infection. Dental screening found multiple untreated dental caries with a root abscess (Fig. 1e). After dental treatment, the patient successfully underwent MV replacement (Fig. 1c). Infective endocarditis often requires management by a team of physicians and surgeons with a variety of areas of expertise [2]. Echocardiography plays an important role in the diagnosis of infective endocarditis as a first-line examination, and should be performed in cases of septic condition without delay repeatedly. It has been reported that modern TTE is inferior to TEE in detecting vegetation in patients with infective endocarditis [3]. TEE should be considered in order to make a correct diagnosis. This is an illustrative case of ‘self-attack’ infective endocarditis of the & Shun Nishino shun-nishino@umin.org

A Case of Combined Valvular Disease with Tricuspid Valve Stenosis

症例は63歳,女性で,比較的希なリウマチ性三尖弁狭窄症を伴う連合弁膜症の診断で3弁置換術を行った.大動脈弁,僧帽弁位の人工弁は,年齢から機械弁を選択し,三尖弁位には,抗血栓性を重視し生体弁を使用した.三尖弁位における人工弁選択についての考察も加えて報告する.