We report a case of emergent redo-mitral valve replacement during pregnancy at 23 week and 4 days of gestation. A 23-year-old woman, who underwent mitral valve replacement with a bioprosthetic valve (Carpentier-Edwards Perimount^® 27 mm) for infective endocarditis 5 years ago, was transferred to our hospital due to severe congestive heart failure. Echocardiography revealed structural valve deterioration of the mitral prosthesis and severe mitral stenosis. Emergent redo-mitral valve replacement with a bioprosthetic valve was performed to save the patient with top priority. Cardiopulmonary bypass was operated under normothermic, high flow, high pressure and pulsatile fashion. Fetal heart rate was continuously monitored during the operation. Although her baby was delivered vaginally just after operation weighing only 520 g, she was treated by the neonatologists successfully.

We experienced 6 cases of intractable perioperative myocardial ischemia with coronary spasm that was successfully treated with fasudil, a Rho-kinase inhibitor. Three of the patients (aged 49-81 years) showed ST elevation on electrocardiograms and abrupt circulatory collapse after off-pump coronary artery bypass grafting. Emergeny coronary angiogram revealed severe spasm of their own coronary arteries and/or bypass grafts. Since intracoronary and/or intragraft injection of isosorbide dinitrate (ISDN) was ineffective, we administered fasudil into the spastic vessels, and that completely resolved the spasm. The other 3 patients (aged 55-77 years) suffered myocardial ischemia during the operation, though intravenous vasodilators including ISDN, diltiazem and nicorandil had been administered continuously. Their ischemia occurred when the aorta was declamped, the pericardium opened, or the bypass graft was anastomosed, respectively. We decided to use fasudil in these cases since ISDN was ineffective, or severe spasm was found on intraoperative inspection. Administration of fasudil successfully relieved the ischemia, and subsequently all 3 patients could be weaned from the cardiopulmonary bypass during the operation. Fasudil completely resolved the myocardial ischemia in all 6 patients. In conclusion, fasudil, a Rho-kinase inhibitor, is a useful agent for perioperative myocardial ischemia including coronary spasm that is resistant to intensive conventional vasodilator therapy. We should administer fasudil and relieve spasms as early as possible to rescue patients with intractable ischemia.

A 37-year-old man presented with extensive myocardial infarction due to total occlusion of the left main trunk, complicated with near-fatal heart failure. An extracorporeal left ventricular assisted system LVAS (NIPRO-Toyobo LVAS) was implanted in our hospital. Although his postoperative course was relatively good, acute cholecystitis occurred on the 31st postoperative day, and emergeney cholecystectomy was indicated. His PT-INR was 4.13 because of taking Warfarin orally, and the cannulas of LVAS passed through his skin at the subxiphoid region. Therefore, we preoperatively transfused fresh frozen plasma quickly to reverse the PT-INR (approximately 2.0) and performed open cholecystectomy via the right side of the para-rectus abdominal muscle. His postoperative course was uneventful, and he is waiting for heart transplantation in our hospital.

The combined method of antegrade and retrograde administration of cardioplegic solution has been established for coronary bypass surgery. We applied this technique in patients undergoing aortic and mitral valve surgery. Between January 1989 and December 1990, 28 patients underwent both aortic and mitral valve replacements. To compare the myocardial protective effect according to the method of cardioplegic administration, they were divided into two groups; Ante group (antegrade, n=15) and Retro group (combined method of antegrade and retrograde, n=13). Aortic occlusion time and cardiopulmonary bypass time were shorter in Retro group. The mean interval of each cardioplegic administration was significantly shorter in Retro group (Ante group, 29.2±4.8min vs Retro group, 24.0±3.8min; p<0.01). These results suggest that retrograde cardioplegia method never disturbs ongoing operation during each delivery while antegrade method often does. Serum CPK-MB at 6hr of reperfusion tended to be less in Retro group (Ante group, 120±80IU/l vs Retro group, 78±50IU/l; p=0.09). The results of postoperative cardiac functions were the same in both groups. We therefore believe that this method is an optimal strategy even in patients with valvular heart disease.

Since late 2013 through March 2014, Japan experienced a rapid rise in measles cases. Here, we briefly report on the ongoing situation and share preliminarily findings, concerns and challenges and the public health actions needed over the coming months and years.

Measles is a notifiable disease in Japan based on nationwide case-based surveillance legally requiring physicians to report all clinically diagnosed and laboratory-confirmed cases within seven days, but preferably within 24 hours. After a large outbreak in 2007–2008 (more than 11 000 cases reported in 2008 alone) and a goal of elimination by April 2015, a catch-up programme using the bivalent measles-rubella (MR) vaccine was offered for grades seven and 12 (ages 12–13 and 17–18 years) from April 2008 through March 2013. During this period, there was an estimated 97% decline in measles notifications, and the cumulative number of reported cases has been steadily declining over the last five years (732 cases in 2009, 447 cases in 2010, 439 cases in 2011, 293 cases in 2012 and 232 cases in 2013). However, since late 2013 through March 2014, the country experienced a resurgence only a year after a large rubella outbreak.