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In both developed Western nations and developing countries, economic growth was based on the development of industrial districts, which were much more organized and institutionalized in modern Japan than economist Alfred Marshall had described. Local trade associations played an important role in enhancing Marshallian externalities, arising from the ease of imitating improved ideas and transacting unfinished products among clustered enterprises by facilitating joint actions in the supply of public goods, such as through the creation of local district brands and through the efficient provision of business information. These activities were clearly beyond the scope of agglomeration economies. This article examines the case of Kiryu, one of the best-known silk weaving districts in Japan.

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We report an autopsy case of a coronary aneurysm with massive adventitial inflammation post-percutaneous coronary intervention with sirolimus-eluting stent (SES) insertion in the left circumflex (LCX) coronary artery for ischemic heart disease 3 years prior to death. The internal elastic membrane was disrupted opposite the site of the eccentric LCX plaque due to injury during stenting, and the adventitia showed massive inflammatory cell infiltration, mainly consisting of eosinophils. The LCX showed aneurysmal dilatation with inflammatory cell infiltration. Inappropriate SES implantation attracted chronic inflammation. Chronic inflammation can lead to the development of coronary artery aneurysms.

SummaryPatients with atrial fibrillation (AF) are at risk of cardioembolism.1,2) Atrial thrombus formation associated with AF typically occurs in the left atrial appendage (LAA);3) therefore, transesophageal echocardiography (TEE) is important for detection of such a thrombus and measurement of LAA flow velocity. 4,5) LAA closure is routinely performed during mitral valve surgery in patients with AF to prevent cardiogenic stroke. 6) We report the case of a 65-year-old woman with severe mitral regurgitation (MR) and AF in whom a giant thrombus formed almost immediately after mitral and tricuspid valvuloplasty and concurrent LAA resection. No atrial thrombus or spontaneous echo contrast (SEC) was detected by TEE before the surgery. However, a giant intramural thrombus was detected in the left atrium 7 days after surgery. It was thought that the atrial dysfunction as well as the change in morphology of the left atrium resulting from the severe MR complicated by AF and congestive heart failure produced a thrombotic substrate. This case suggests that careful surveillance for thrombus formation and careful maintenance of anticoagulation therapy are needed throughout the perioperative period even if no SEC or thrombus is detected before surgery. (Int Heart J 2015; 56: 668-670) Key words: Atrial thrombus, Mitral regurgitation, Mitral valve surgery P atients with atrial fibrillation (AF) are at risk of cardioembolism. 1,2) Atrial thrombus formation associated with AF typically occurs in the left atrial appendage (LAA);3) therefore, transesophageal echocardiography (TEE) is important for detection of such a thrombus and measurement of LAA flow velocity, 4,5) especially in patients with AF due to mitral regurgitation (MR). To prevent cardiogenic stroke, LAA closure is routinely performed during mitral valve surgery in patients with AF. 6) Case ReportA 65-year-old woman was referred to our hospital because of severe MR and dyspnea on effort. Her medical history included chronic AF, hyperuremia, and a previous myocardial infarction. A systolic murmur was heard at the apex, and coarse crackles were heard in all lung fields. Chest radiography revealed an increased cardiothoracic ratio (71%) with enlarged atria. Electrocardiography showed AF of 75 bpm. Transthoracic echocardiography revealed enlargement of the left atrium (74 × 67 mm), severe MR, and tricuspid regurgitation (Figure 1). Left ventricular (LV) systolic function was normal with an LV ejection fraction (EF) of 72%, and LV wall thickness was within normal range. There was no chorda tendinea tear or mitral valve prolapse; however, the anterior and posterior leaflets of the mitral valve showed myxomatous degeneration. Despite the enlarged atrium and chronic AF, TEE showed no thrombosis or spontaneous echo contrast (SEC) in any cardiac chamber. It did show, however, massive mitral regurgitant flow reaching the roof of the left atrium (Figure 2). LAA peak emptying velocity (LAAEV) was 28 cm/sec, and LAA peak filling velocity (LAAFV) was 51 cm/sec. The patient was trea...