We report a patient with candidemia, and remote organ infection, who underwent surgical treatment of aortic valvular stenosis. The patient was a 77-year-old man. Candida glabrata was detected in a blood culture during pharmacological treatment for pyelonephritis associated with vesicoureteral transition stenosis. A ureteral stent had been placed to preserve urine outflow, and vesicoureteral surgery had been scheduled. However, the urological surgery had to be performed first because of severe aortic valvular stenosis. After long-term (5 months) of antifungal treatment, Candida was no longer detected in the urine or blood cultures, but the serum β-D-glucan level did not fall below the reference value (21.6 pg/ml at the last measurement). It was difficult to control the infection further, and we decided to perform aortic valve replacement. There was no evidence of endocarditis at surgery, but pathological examination revealed traces of the fungus in the tissue of the aortic valve. The post-operative course was uneventful, and urological surgery was carried out 45 days later. Infection recurred when the antifungal medication was temporarily discontinued. The infection was then controlled by resumption of the antifungal medication. The patient has been free of recurrence for the past year since the aortic valve replacement. In the present case, in which a mycosis from a remote source was not readily eradicated prior to valve replacement, we were able to obtain good results by first administering long-term antifungal medication to quell the inflammation as much as possible.

We herein report a 79-year-old man who developed anaphylactoid purpura after thoracic endovascular aortic repair, which he underwent for a distal aortic arch aneurysm of saccular type. On the third postoperative day he had purpura over his lower legs and abdomen accompanied by intermittent fever. His serum C-reactive protein concentration reached a maximum of 12 mg/dl, and remained at around 4 mg/dl thereafter. A dermatologist diagnosed anaphylactoid purpura ; this gradually improved with topical steroid and the nature and dosage of the oral medication. We suspected the presence of malignancy ; however, appropriate investigations failed to identify a cause for the purpura. During 6 months of outpatient follow up he has been free of recurrence. Anaphylactoid purpura occurs most frequently in childhood, often after an upper respiratory tract infection, whereas this condition is rare in adults. Triggers for anaphylactoid purpura include surgery, infection, certain medications, chronic lung, liver, or renal failure, and malignancy. We believe that the stress of undergoing thoracic endovascular aortic repair was the trigger in this case. Anaphylactoid purpura may be complicated by arthritis, gastrointestinal involvement and renal manifestations. There were no such complications in this case.

Cardiac cachexia is a terminal clinical stage of valvular heart disease, and there is high incidence of postoperative mortality and morbidity. Cardiac cachexia was considered to be present when patients with mitral lesions showed all of the following criteria; 1. mitral valve disease associated with relative tricuspid regurgitation, 2. lean body below 80% of %standard weight, 3. NYHA functional class IV, 4. marked hepatomegaly and congestive liver dysfunction (ICG retention rate over 30%.) Ten patients satisfying the criteria were divided into two groups according to the interval of postoperative respiratory care. Group 1 (n=5), patients necessitating mechanical ventilation for more than 5 days after operation, Group 2 (n=5), patients requiring ventilation up to 5 days after operation. Pre- and postoperative nutrition, respiratory and circulatory states were evaluated for these two groups. In pre- and postoperative periods, intravenous hyperalimentation was administed in two groups, during the postoperative period, two patients of group 1 required tube feeding. In the pre-operative period, three patients in group 1 needed respiratory care (1 intra-tracheal intubation and 2 oxygen mask inhalation). The results were as follows; 1. The duration of illness was longer in group 1 than in group 2. 2. In the postoperative period, there was no difference in the amount of catecholamine, postoperative course and prognosis between groups 1 and 2. Surgery for valvular disease is possible even in cases of cardiac cachexia, if sufficient management of nutritional state, respiration and circulation can be maintained.

We evaluated the indications and limitations of IABP support for weaning for pump and postoperative heart failure after artificial valve replacement. Driving IABP as cardiac support in cases of acute cardiac failure during and after operation, it is most effective for transient cardiac failure-associated coronary artery spasms during and post operation, but it is not effective and is indeed limited for patients who need long term extracorporeal circulation because of operative technical failure, insufficient cardioplegia and delayed right ventricular failure after operation. The latter groups, in which IABP is insufficiently effective need additional assist devices such as V-A bypass and ventricular assist device (VAD).

We studied the effects of intermittent tepid blood cardioplegia on patients with prolonged aortic cross-clamping. Forty patients undergoing coronary artery bypass grafting with cross-clamp time of greater than 120 minutes were studied. The patients were divided into two groups according to the cardioplegic solutions, cold (4°C) crystalloid cardioplegia (Cold) and tepid (30°C) blood cardioplegia (Tepid). Cardiac function, myocardial enzyme and clinical outcomes were compared between the groups. Mean aortic cross-clamp time were 150±10 minutes in the Cold group and 149±4 minutes in the Tepid group. Recovery rate of spontaneous rhythm after cross-clamp removal and postoperative left ventricular stroke work index were significantly greater in the Tepid group than those in the Cold group. Duration of ventilation and ICU stay were significantly shorter and total release of CK-MB, requirements of dopamine during 48 hours after the operation and the incidence of low-output syndrome were significantly less in the Tepid group. There were no early deaths in the Tepid group versus three early deaths in the Cold group. In conclusion, intermittent tepid blood cardioplegia provided superior postoperative cardiac function and clinical results to conventional cold crystalloid cardioplegia, thus the technique appears to be safe for patients requiring prolonged aortic cross-clamping.

Perioperative changes in thyroid function and hemodynamic state were studied in 6 hypothyroid patients and 15 euthyroid patients who underwent coronary artery bypass grafting. Serum free T₃ and total T₃ concentrations declined significantly in hypothyroid patients after the surgery. Serum total T₃ concentration decreased significantly also in euthyroid patients, indicating the occurrence of“euthyroid sick syndrome”in this group. Hypothyroid patients resulted in significantly lower left ventricular stroke work index despite greater central venous pressure and pulmonary capillary wedge pressure, and greater requirements of dopamine and dobutamine compared with those in euthyroid patients. The results indicated poorer postoperative cardiac performance in hypothyroid patients. Serum free T₃ concentration after cardiopulmonary bypass demonstrated a significant positive correlation with left ventricular stroke work index measured simultaneously. Preoperative serum free T₃ concentration showed a significant negative correlation with the postoperative dopamine and dobutamine requirements. Therefore, the results suggest that free T₃ has inotropic effects and the concentration of this hormone can be a predictor for a incidence of postoperative low cardiac output. In conclusion, since hypothyroid patients undergoing coronary artery bypass grafting are prone to have low cardiac output status, careful perioperative management, including hormone replacement therapy, is required for the patients.

The effects of human atrial natriuretic peptide (HANP, carperitide) were studied in 21 patients undergoing mitral valve surgery. The patients were randomized to receive either no carperitide treatment (control group, n=10) or carperitide (HANP group, n=11). Their hemodynamic status, diuresis and renal function were assessed perioperatively. The HANP group received continuous intravenous infusion of carperitide for 3 hours at a rate of 0.05μg/kg/min 3 hours after cardiopulmonary bypass. The HANP group had significantly lower systemic vascular resistance and less temperature difference between the rectum and the sole, and significantly greater cardiac index compared with those in the control group during infusion of carperitide, suggesting the improvement of cardiac performance by reducing afterload. The HANP group also had greater urinary output during the administration of carperitide, suggesting the significant diuretic effect of the regimen. The results indicated that the administration of carperitide may be a viable alternative strategy for the management of patients with postoperative heart failure. However, since transient oliguria was observed in 2 hypovolemic patients after the discontinuation of carperitide, careful monitoring is required during and after the infusion of the regimen in such patients.

Cor triatriatum is one of the rare congenital cardiac malformations and once the diagnosis is correctly established, this is amenable to surgical correction. We reported a case of 25-year-old male of cor triatriatum, who had symptomes of easy fatiguability. The diagnosis of cor triatriatum was suspected preoperatively by two-dimensional echocardiogram at first, detecting abnormal diaphragm in the left atrium, and it was confirmed by color Doppler echocardiogram and transesophageal two-dimensional echocardiogram. Cardiac catheterization revealed high pulmonary capillary wedge pressure and the abnormal diaphragm in the left atrium was showed by the pulmonary arteriography. On the operation, the abnormal diaphragm was excised by the trans-septal approach, which had a small fenestration of 8mm in diameter at posterolateral site. Some considerations for clinical diagnosis and surgical treatment are discussed.

The effects of milrinone, a phosphodiesterase III inhibitor, were studied in patients with heart failure following coronary artery bypass grafting. Twenty patients with heart failure (either a cardiac index of less than 2.0l/min/m² or a pulmonary capillary wedge pressure of greater than 12mmHg) were divided into two groups according to whether or not they received postoperative milrinone administration. The control group (n=10) received no milrinone treatment and the milrinone group (n=10) received intravenous milrinone infusion at a speed of 0.5μg/kg/min postoperatively. The hemodynamic measurements were made perioperatively and clinical results were accessed perioperatively. Within-group comparison revealed a marked (p<0.05) decrease in pulmonary capillary wedge pressure and systemic vascular resistance in the milrinone group. Cardiac indices were significantly (p<0.05) greater in the milrinone group than those in the control group and within-group comparison revealed a significant (p<0.05) increase in left ventricular stroke work index in the milrinone group. There was no significant difference in rate pressure product in between- and within-group comparison. The milrinone group had a significantly (p<0.05) lower temperature difference between the rectum and the sole, and significantly (p<0.05) less catecholamine requirements postoperatively. Milrinone was not associated with a significant increase in the prevalence of adverse effects. The results suggest that milrinone possesses positive inotropic and vasodilatory effects in patients with heart failure following coronary artery bypass grafting. In addition to catecholamines and vasodilators, milrinone may become a useful agent in the treatment of patients with postoperative heart failure.

Ventricular Septal Defect (VSD) is the most frequent cardiovascular anomaly. VSD causes pulmonary hypertension through stenotic changes in the pulmonary vasculature, and this progress depends on the size of defect and associated cardiovascular anomalies. Since surgical repair has been performed in childhood for patients without a tendency toward spontaneous closure of VSD, operations in elderly patients, especially those aged over 40, are rare. We report an elderly patient with VSD complicated with severe pulmonary hypertension who underwent surgical repair. A 66-year-old man was admitted to our hospital because of general fatigue, chest oppression and palpitations. The pulmonary to systemic pressure ratio was 0.66. The oxygen saturation stepped up at the right ventricle level. The pulmonary to systemic blood flow ratio was 2.9, shunt ratio was 71% and resistance ratio was 0.12. The VSD was 18mm in diameter at the perimembranous trabecula and was closed with a Dacron patch through a right atrium incision. The lung biopsy specimen revealed little occlusive pulmonary vascular disease, Grade I according to the Heath-Edwards criteria. The patient had an uneventful recovery.