Purpose: The objective of this report is to evaluate our surgical approach to complete atrioventricular septal defect with tetralogy of Fallot (TOF) and to determine the best treatment for this malformation.Methods: From 2007 to 2012, 17 children underwent surgical correction of complete atrioventricular septal defect with TOF. Nine of these patients underwent complete correction, two underwent one and a half ventricle repair, and six underwent univentricular repair.Results: There was 1 in-hospital death and 1 late death. Patients with lower weight required longer intensive care unit stay (P <0.05; r = –0.834). Follow-up data were available for all patients who survived the operation (range, 3–60 months). The Kaplan-Meier curve indicated that 5-year survival was 88.2%. All survivors remained in good condition in New York Heart Association (NYHA) class I or II.Conclusion: Complete repair of atrioventricular septal defect with TOF has got favorable outcomes in terms of mortality and reoperation rate. Unbalanced atrioventricular septal defect with TOF can be managed well with one and a half ventricle repair. Two-patch technique through a transatrial approach alone is a good treatment choice for patients. Management of right ventricular outflow tract (RVOT) is similar to that of isolated TOF.

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Purpose: We retrospectively investigated the pathological diagnoses of pulmonary lesions presenting as pure ground-glass opacities (GGOs) to evaluate the risk of invasive malignancy.Methods: We examined 191 GGO lesions, including 114 pure GGO and 77 mixed lesions, in 160 patients who underwent resection between January 2008 and December 2010.Results: Of the 114 pure GGO lesions, 14 (12%) were diagnosed as invasive lung cancer and 16 (14%) as minimally invasive adenocarcinoma. Twenty-one lesions exhibited pleural indentation on high-resolution computed tomography (HRCT), and 5 of these were diagnosed as invasive cancer, indicating an invasive tendency of pure GGO lesions with pleural indentation (odds ratio, 2.64). Of 14 pure GGO lesions positive on positron emission tomography (PET), 8 were diagnosed as invasive lung cancer, indicating an invasive tendency of pure GGO lesions with PET positivity (odds ratio, 16.0; p <0.001; sensitivity, 67%; specificity, 89%).Conclusion: Invasive lung cancer accounted for 12% of the pure GGO lesions. Pure GGO lesions should be carefully monitored by periodic chest computed tomography, and surgical resection is recommended when they exhibit pleural indentation on HRCT or positivity on PET.

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Objective: Despite recent advances in video-assisted thoracoscopic lobectomy, some technical limitations still remain. Our current study purpose was to determine if the vessel sealing system (VSS) has utility in this procedure.Method: 112 patients who underwent an anatomic pulmonary lobectomy at our institute were evaluated retrospectively. The burst pressure of pulmonary vessels, which was divided into VSS (VSS group; n = 44) or manual ligature (ligature group; n = 53) groups, was measured experimentally in transected lungs. Perioperative clinical data was also retrospectively evaluated in patients treated with (VSS group) or without using VSS (n-VSS group).Results: Burst pressures achieved adequate strength in both the VSS (600.0 ± 436.8 mmHg) and ligature (1057.4 ± 462.3 mmHg) groups. Compared with the n-VSS group, the VSS group patients showed lower intraoperative blood loss (115.4 ± 181.1 vs. 183.3 ± 159.1 ml), lower chest fluids by 3rd post-operative day (POD) (533.8 ± 264.8 vs. 705.3 ± 339.3 ml) and a shorter period of chest tube duration (4.1 ± 1.2 vs. 5.4 ± 2.4 days). No serious complications or perioperative (30 days) deaths occurred in either group.Conclusion: The VSS device has the advantage in pulmonary lobectomy procedures, especially those involving video-assisted thoracic surgery (VATS).

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Background: A signaling pathway of the small GTPase Rho and Rho-associated coiled-coil-forming protein kinase (ROCK), regulates the contraction of endothelial cells. We studied the effects of Y-27632, a specific ROCK inhibitor, to clarify the role of Rho/ROCK in the pathogenesis of ischemia-reperfusion lung injury in a rat model of single-lung transplantation (LTX).Methods: We flushed 5 donor rat lungs with Euro-Collins solution, and 5 donor lungs with Euro-Collins + Y-27632, 0.03 mg/ml, and preserved the lungs for 6 h at 4°C before reperfusion for 4 h. The 5 rat recipients of Y-27632-treated lungs also received a 10-mg/kg bolus of Y-27632 i.p. 30 min before reperfusion.Results: Pretreatment of the donor lungs and recipient rats with Y-27632 prominently suppressed the post-LTX edema, while the permeability index was only slightly decreased. The (1) numbers of neutrophils and macrophages, and (2) tumor necrosis factor (TNF)-α concentration, were significantly lower in the bronchoalveolar lavage fluid of treated than untreated lungs.Conclusions: Y-27632 (1) inhibited the migration of inflammatory cells into the alveolar space, (2) decreased the production of TNF-α, and (3) attenuated the edema after LTX. Endothelial Rho and ROCK may play an important role in the pathogenesis of post-LTX injury.

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Purpose: To review our institutional surgical outcomes with primary mediastinal cysts (PMCs) and elucidate the clinicopathological differences among several histological PMC variants.Methods: We retrospectively reviewed 108 patients who underwent surgery for PMC at our institution between 1997 and 2012.Results: There were 54 thymic cysts (TCs), 26 bronchogenic cysts (BCs), 16 mature cystic teratomas (MCTs), 11 pericardial cysts (PCs), and 1 esophageal duplication cyst. Surgical approach was via thoracoscopy in 44, thoracotomy in 24, median sternotomy in 39, and hemiclamshell incision in 1. Pathological complete resection was achieved in all patients. Postoperative complications occurred in 13 patients. There was no postoperative mortality. All patients were recurrence-free after a mean follow up of 41 ± 26 months. MCT was significantly associated with larger cyst size (p <0.001) more frequent combined resection of invaded organs (p <0.001), more intraoperative bleeding (p = 0.005), and longer duration of operation (p = 0.022) than the 3 other groups (TC, BC, and PC).Conclusion: Surgical treatment for PMC is safe and efficacious regardless of approach. Patients with MCT may require more aggressive surgeries than those with other histological variants, reflecting their potential for invasion into surrounding structures and larger cyst size.

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Purpose: The use of staplers for thoracic surgery has been regarded as a safe procedure though sometimes adverse events (AEs) of stapling are experienced. The aim of this study is to analyze AEs of lung tissue stapling.Methods: A retrospective multi-institutional review was conducted by 27 institutions of the Central Japan Lung Cancer Surgery Study Group. During the research period, lung tissue stapling was performed 10908 times.Results: Total number of AEs related to stapling was 81 (0.74%). Seventy events occurred intraoperatively and 11 events occurred postoperatively. Intraoperative stapling AEs were air leakage (n = 26), laceration of the adjacent lung tissue (n = 23), stapling failure (n = 14), oozing (n = 4), and others (n = 3). The postoperative AEs were prolonged air leakage (n = 9), bleeding from the chest wall (n = 1), and postoperative bleeding (n = 1). Only one case died of acute exacerbation of interstitial pneumonia which was induced after completion lobectomy to cure postoperative bleeding. No relationship was seen between the incidence of AE and cartridge colors or compression types of staplers except the length of cartridges.Conclusion: Lung tissue stapling in thoracic surgery was safe. The most frequent cause of AEs was stapler-tissue thickness mismatch. The appropriate selection of the cartridge color may decrease the AE incidence of the lung tissue stapling.

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Background: We conducted a study on photodynamic diagnosis (PDD) using autofluorescence in video-assisted thoracic surgery for minute intrathoracic small dissemination or early malignant pleural mesothelioma.Methods: Autofluorescence is the spontaneous emission of light that occurs when mitochondria, lysosomes, and other intracellular organelles absorb light. In normal tissues, green autofluorescence of approximately 520 nm is observed in response to 400–450 nm blue excitation rays. However, in cancer lesions, green autofluorescence is reduced due to thickening of the mucosal epithelium, a decrease in autofluorescent substances, etc., and the color spectrum thus shifts to red-violet. This phenomenon is the basis of PDD.Results: The color spectrum shift was observed in all tumors located on the pleural surface but not in cases with pleural fibrous disease. Among patients with primary lung cancer, those with pleural infiltration (pl) scores of 1 or greater showed color spectrum shifts due to reduced autofluorescence.Conclusion: Localization of pleural lesions by autofluorescence imaging was found to be useful. In primary lung cancer cases, differentiation between pl0 and pl1 lesions appears to be useful for determining therapeutic strategies including surgical procedures.

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Background: The aims of this study are (1) to investigate the occurrence rate of postoperative complications in patients ≥ 80 years old after cardiac surgery and (2) to elucidate the impact of the most common postoperative complications on mortality.Methods: Between January 1998 and December 2007, 649 patients aged over 80 years received isolated first-time coronary artery bypass graft (CABG), isolated aortic valve replacement (AVR) or a combination of both in our institute. Prospectively entered patient data were analyzed with respect to major complications and outcome parameters.Results: Acute renal failure (55.0% vs. 7.5%, p = 0.0001), low cardiac out-put syndrome (43.1% vs. 8.8%, p = 0.0001), sepsis (52.0% vs. 10.3%, p = 0.0001), prolonged respiratory failure with tracheotomy (29.0% vs. 11.0%, p = 0.002), re-thoracotomy due to bleeding (26.9% vs. 10.6%, p = 0.0001), and postoperative laparotomy (30.8% vs. 11.5%, p = 0.033) had a significant impact on mortality. A multivariate analysis revealed that advanced age (OR 1.130, 95%CI; 1.017–1.256, p = 0.023), low output syndrome (OR 5.094, 95%CI; 1.1635–15.871, p = 0.005), renal failure (OR 8.128, 95%CI; 3.347–19.742, p = 0.0001) and sepsis (OR 4.975, 95%CI; 1.420–17.426, p = 0.012) as independent risk factors.Conclusions: The present study demonstrates that among major complications, low output syndrome, renal failure requiring renal replacement therapy and sepsis, dramatically impaired the postoperative course patients aged over 80 years undergoing CABG, AVR or combined CABG and AVR.

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Purpose: Renal dysfunction affects outcomes of cardiac surgery, although its role in mitral valve operation has been limitedly documented.Methods: Two hundred and ten patients who underwent mitral valve operation between 2004 and 2011 were divided into 3 groups according to preoperative estimated glomerular filtration ratio (eGFR): group A (eGFR ≥60 ml/min/1.73 m², n = 102), group B (eGFR, 59–30 ml/min/1.73 m², n = 92) and group C (eGFR <30 ml/min/1.73 m², n = 16).Results: Freedom from all-cause and cardiovascular death at 5 years was 77.2% and 93.0%, respectively. No significant differences existed between the 3 groups. In contrast, there was a significant difference in freedom from major adverse cardiovascular events (MACE) between groups (70.4%, 57.1%, and 42.8% in group A, B, and C, respectively; p = 0.008). By univariate and multivariate analysis, eGFR <60 ml/min/1.73 m² (HR: 1.92, 95% CI: 1.02–3.68, p = 0.044) and left ventricular ejection fraction <40% (HR: 2.69, 95% CI: 1.17–6.23, p = 0.02) were independent risk factors of MACE, although serum creatinine failed to represent an independent risk factor.Conclusion: Patients who underwent mitral valve surgery had acceptable perioperative and long-term survival, irrespective of preoperative renal function. However, eGFR <60 ml/min/1.73 m² was an independent predictor of late MACE.

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Background: Increasing evidences indicated that adipose-derived mesenchymal stem cells (ADMSCs) can stay survive, then gradually proliferate and differentiate into myocardial cells after transplanted into damaged areas and improve function of heart.Methods: In this article, ADMSCs were isolated from adipose tissue of Wistar rats and cultured. When treated with 5-azacytidine (5-aza), ADMSCs were differentiated into myocardial cells, then we implant these cells into myocardium of rats of DCM to observe cell population and differentiation and compare cardiac function and hemodynamics changes before and after transplantation.Results: The expression of Cardiac-specific markers indicated that ADMSCs which were isolated from adipose tissue of Wistar rats can differentiate into various cell types. Meanwhile, the treatment group displayed a higher level of LVESP, left ventricular intraventricular pressure (+dP/dt max), left ventricular intraventricular pressure (–dP/dt max) and left ventricular EF (%) than the control group. Altogether, these results indicate that heart systolic and diastolic function of rats of DCM was significantly improved meanwhile ventricular dilatation remodeling was inhibited after ADMSCs transplantation.Conclusions: Therefore, this research provides an experimental basis for further clinical application of ADMSCs transplantation for the treatment of DCM and non-ischemic HF.

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Lung segmentectomy with bronchial variation has rarely been reported. We report the case of a lung cancer patient with variant anatomy of the right upper lobe bronchus.Thoracoscopic posterior segmentectomy of the right upper lobe was performed. Variant bronchus and related blood vessels were confirmed preoperatively by three-dimensional multidetector computed tomography (3D-MDCT), which facilitated visualization of the patient's anatomy during surgery.

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Meningiomas are generally benign tumors, but rarely metastasize outside of the central nervous system. A 25-year-old female was admitted to our institute because of an abnormal shadow on her chest x-ray. A computed tomography (CT) scan showed a 3-cm, well- circumscribed mass in the right lower lobe of the lung. We performed thoracotomy and resected three pulmonary tumors at the right lung and diaphragm. Histological examination revealed a benign meningothelial meningioma. Six months later, she complained of heaviness of her head and a head CT scan revealed an intracranial mass. A craniotomy was performed and a brain tumor was found to be histologically identical to the lung tumors. During the 21 years since the first operation, we performed three times of pulmonary and pleural metastasectomies and two times of resection of intracranial local recurrences. All of those tumors were meningothelial meningioma without malignant change. The patient is alive without metastasis after the last resection of metastatic tumors.

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We report a 51-year-old man who was diagnosed with concomitant coronary artery disease and systemic lupus erythematosus (SLE). He required urgent coronary artery bypass grafting (CABG) before the initiation of steroid therapy. Steroid therapy was initiated on postoperative day 2 due to the aggravation of SLE. However, he displayed persistent infection and fever, and the steroid dose was gradually decreased, resulting in the worsening of SLE by postoperative day 21. We closely monitored his infection status and renal function and regulated the steroid dose accordingly. The patient stabilized and was discharged on postoperative day 60 without further complication. Meticulous post-operative management is required in acute SLE patients who need open heart surgery.

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