Interest in aortic valve repair has been growing for more than a decade. Since ross and associates 1) first introduced single cusp enlargement, cusp extension or replacement of aortic valve insufficiency has been used with rheumatic and congenital aortic valve disease. There is more interest on the effectiveness and durability of the leaflet extension technique with autologous pericardium and long-term clinical results. A 29-year-old woman had suffered from aortic valve insufficiency after congenital heart disease operation. Echocardiography and computed tomography showed right cusp shortening with severe aortic valve regurgitation. We perfomed right cusp extension with bovine pericardium and central plication. According to some reports, the stability of autologous pericardium being better than bovine pericardium, but this case could not use a autologous pericardium because of a previous operation. The patient had an uneventful postoperative course and pregnancy became possible.

Dextrocardia is a rarely seen cardiac malposition in which the heart is pointed toward the right side of the chest. A 77-year-old woman was admitted to our hospital with exacerbated exertional dyspnea. Cardiac examinations revealed severe mitral regurgitation due to prolapse of the posterior mitral leaflet in mirror-image dextrocardia (situs inversus, L-loop ventricles, and inverted great arteries). Mitral valve replacement using a bioprosthesis and pulmonary vein orifice isolation were successfully performed. The operative view of the surgeon standing on the left side of the patient showed mirror-image dextrocardia represents left-right reversal compared with normal heart structure. This provided some challenges in establishing cardiopulmonary bypass and performing intracardiac maneuvers. The mitral valve was on the left side of the surgeon and different needle grips, different angle of suturing, and the choice of forehand or backhand suturing were required to obtain secure suturing in the mirror-imaged mitral annulus.

An 82-year-old woman, who had suffered from idiopathic thrombocytopenic purpura (ITP) treated with oral steroids, was admitted to our hospital with worsening exertional dyspnea. Cardiac examinations revealed severe aortic stenosis with left ventricular dysfunction. High dose intravenous gammaglobulin therapy (400 mg/kg/day) for 5 days was conducted to increase the platelet count prior to the operation. However, a decrease was observed in the platelet count from 2.1×10⁴/mm³ on admission to 1.9×10⁴/mm³ before surgery. Without additional therapy, aortic valve replacement using a 19 mm bioprosthesis was performed with cardiopulmonary bypass (CPB). Tranexamic acid (20 mg/kg/h) was continuously infused from the skin incision to the end of the surgery. Forty units of the platelet concentrates were transfused just after weaning from CPB. The patient had no hemorrhagic complications. We believe that intraoperative administration of tranexamic acid combined with platelet transfusion is effective to reduce perioperative bleeding for a patient with ITP unresponsive to preoperative gammaglobulin therapy.

We report 2 cases of postinfarction ventricular septal perforation (VSP) attributable to obstruction of the right coronary artery. Case 1 was a 63-year-old man in whom VSP developed after percutaneous coronary angioplasty for complete obstruction of the right coronary artery. He developed papillary muscle rupture intraoperatively, requiring mitral valve replacement and subsequent treatment for right-side heart failure. He was discharged l7 weeks after surgery. Case 2 was a 77-year-old man. During catheterization following the detection of 99% obstruction of the #2 segment of the right coronary artery, VSP was found and the patient underwent emergency surgery. Postoperative echocardiography and ventriculography did not reveal a residual shunt or mitral regurgitation (MR). However, he suddenly developed acute MR in the 4th postoperative week and died of acute heart failure. VSP attributable to obstruction of the right coronary artery is difficult to repair surgically because of its anatomical location, among other reasons, and mitral valve replacement is sometimes needed if VSP is accompanied by necrosis of the mitral valve papillary muscle. Appropriate care is therefore needed in this case.

Infected femoral artery aneurysm is difficult to treat because of the risk of reinfection and anastomosis. The treatment of choice has been a topic of much controversy. Revascularization is mandatory for limb salvage after excision of infected grafts. Revascularization requires various ingenious techniques such as retro-sartorius bypass and obturator bypass. We treated a patient with suspected infection of an aorta-femoral graft, using femoro-femoral crossover bypass in front of the pubis and inside of the thigh muscle. We performed complete debridement of infected tissue. After resterilization of the operative field once more and exchange of all the instruments we performed revascularization detouring around areas of focal infection, using autogenious vein graft through the front of the pubis and inside of the thigh muscle to reach the left superficial femoral artery.

Right-sided infective endocarditis (IE) accounts for 5% to 10% of all IE. Compared with left-sided IE, antibiotic treatment is effective in about 70% of cases. The timing of surgical treatment for right-sided IE is therefor controversial. A 26-year-old woman had suffered from tricuspid valve endocarditis with DIC. There was no evidence of any previous cardiac event or dental treatment. Echocardiography showed a large vegetation attached to the anterior leaflet of tricuspid valve with moderate tricuspid regurgitation. We removed the vegetation with a part of the anterior leaflet and performed tricuspid valvuloplasty and annuloplasty. The patient had an uneventful postoperative course and received intravenous antibiotic treatment for a further 4 weeks.

A 47-year-old man had suffered from high grade fever and dyspnea for 10 days. He was transferred to our hospital in a condition of shock. Echocardiography showed severe diffuse hypokinesis of left ventricle (EF 21%), and multiple mobile thrombi in the left ventricle. Under a diagnosis of LV thrombi due to acute myocarditis, transatrial removal of LV thrombi was performed using video-assisted cardioscopy. He was weaned from cardiopulmonary bypass under IABP support. Postoperatively, he suffered from thromboembolism of the cerebral and right brachial artery. Thrombectomy of the right brachial artery and anticoagulation therapy was performed. IABP was removed on POD 3, and he no longer needed respiratory control on POD 4. Echocardiography on POD 6 showed marked improvement of the LV contraction (EF 52%). After rehabilitation, he was discharged on POD 23 on foot. Video-assisted cardioscopy allowed transatrial removal of LV thrombi, and preserved left ventricular function by avoiding ventriculotomy. Perioperative thromboembolism must be taken care of for a patient with multiple LV thrombi.