A case of infectious endocarditis was surgically treated by mitral valve replacement. The patient had previously undergone presternal subcutaneous colonic interposition as reconstruction surgery due to esophageal and gastric cancer. This artificial esophagus prevented the central sternotomy that is necessary for cardiac surgery. In cases where sternotomy is difficult, anterolateral right intercostal thoracotomy is useful. Arterial cannulation was performed via the femoral artery; cannulations for venous drainage were performed in the femoral vein for the inferior vena cava and in the right jugular vein for the superior vena cava in order to establish cardiopulmonary bypass circulation. Under the condition of ventricular fibrillation and a body temperature of 25°C, the mitral valve that had been destroyed by infection was resected by exposure of the left atrium on its right side. An artificial Saint Jude Medical mechanical valve, 29mm in diameter, was implanted. The thorax was insufflated with carbon dioxide gas to prevent air embolization. An aortic vent tube was used for air drainage from the cardiac output. Although a seizure occurred once after the operation, the post-operative course was very stable; currently, the patient (NYHA I) is in very good condition with no recurrence of the cancer.

We describe the case of an 83-year-old woman who underwent surgical repair for abdominal aortic aneurysm with horseshoe kidney. Preoperative computed tomography (CT) scans showed the presence of not only the principal bilateral renal arteries but 2 accessory renal arteries originating from the right common iliac artery. The left accessory renal artery had 2 branches supplying each of the lower poles of the kidneys. We performed open surgery for artificial graft replacement by dividing the isthmus. The isthmus was formed of fibrous connective tissue therefore we dissected the isthmus sharply and sutured edges. A urinary fistula was absent. Since supply to the right renal lower pole via the left accessory artery was negligible, the artery was ligated. We performed this procedure safely and achieved a successful outcome.

A case of intracranial hemorrhage during valve surgery for infective endocarditis is reported. The patient was a 40-year-old man whose chief complaint was fever of unknown origin. Echocardiography demonstrated severe mitral regurgitation with vegetations. A blood culture demonstrated Streptococcus salivarius. He was treated with penicillin G and gentamicin for 6 weeks. Magnetic resonance imaging (MRI) was performed 10 days before surgery, but acute infarction, hemorrhage, or mycotic aneurysm were not observed. Mitral valve replacement was performed with a mechanical valve. Postoperatively, the patient had hemiplegia. Hemorrhage was visible in the right thalamus and left cerebellum on computed tomography. Ventricular drainage and removal of the cerebellar hematoma were performed the next day. These results suggest that to avoid cerebral complications during cardiac surgery for infective endocarditis, strict activated clotting time control and MRI just before surgery appear to be necessary.

Recent studies have reported parasympathetic ganglia supplying the regions around the sinoatrial node (SAN) are situated in the pulmonary vein fat pad (PVFP). Otherwise, in coronary artery bypass grafting (CABG) without cardiopulmonary bypass, cardiac surgeons expect effective support technique on heart rate. The purpose of this study was to determine the feasibility of inducing sinus bradycardia by stimulating these parasympathetic nerve fibers to the SAN in humans. Nine patients were anesthetized and median sternotomy was performed. Bipolar electrodes were sewn onto PVFP to stimulate parasympathetic nerve fibers to the SAN. PVFP was electrically stimulated with a 4-9 V pulse of 0.1msec and a frequency of 5, 10, 20, or 50Hz. Sinus bradycardia was induced by selective stimulation of the parasympathetic nerve fibers to the sinoatrial node. The response was frequency-dependent up to 20Hz. Heart rate was significantly reduced from 90.1±12.4 to 71.4±15.7 (beats/min) at 20Hz. This technique could be applied for reducing heart beats in CABG without cardiopulmonary bypass. However, there are problems in maintaining of the effect.

Anticoagulation management in cardiac surgery can be difficult in patients with heparin-induced thrombocytopenia (HIT). We report a patient who underwent reoperation of cardiopulmonary bypass (CPB) using argatroban in combination with nafamostat mesilate. A bolus of 0.25 mg/kg argatroban was administered, followed by continuous infusion of 5-10 μg/kg/min argatroban and 100 mg/h nafamostat mesilate. No complications such as thrombosis were observed during either CPB or the perioperative period. Although we used argatroban and nafamostat mesilate, which has a shorter half-life than argatroban, the anticoagulant effect was prolonged, and the patient had an uneventful postoperative course despite requiring substantial blood transfusion.

A 66-year-old woman complained of dyspnea due to congestive heart failure, and was given a diagnosis of severe aortic insufficiency. Antiphospholipid syndrome and idiopathic thrombocytopenic purpura (ITP) had been diagnosed with 9 years previously. We planned preoperative plasma exchange and steroid pulse infusion to reduce the level of auto-antibodies for phospholipids. The aortic valve replacement was performed safely. Anticoagulant therapy with low molecular weight heparin and oral steroid therapy was administered after the operation to avoid thrombosis or bleeding. The patient's postoperative course was stable. She was discharged without any complication. In conclusion, preoperative plasma exchange and steroid pulse infusion, postoperative anticoagulant therapy and oral steroids resulted in a favorable outcome in a case of heart surgery for a patient with antiphospholipid syndrome.

We report the findings in a 75-year-old woman who was given diagnosis of rupture of the internal thoracic artery (ITA) and was successfully treated by coil embolization. The patient suddenly felt chest pain, and a chest CT revealed a mediastinal hematoma. She was suspected to have an acute aortic dissection, and therefore transferred to our hospital. Upon careful examination, a CT showed a hematoma in the superior mediastunum and the extravasation of the left internal thoracic artery. Emergency coil embolization was thus performed to stop the bleeding. After the embolization, no further hemorrhaging was observed. The patient was uneventfully discharged in a healthy state 2 weeks later. Rupture of the internal thoracic artery is rare. However, it is important to include this potential disease in the differential diagnosis when encountering a patient presenting with an atraumatic mediastinal hematoma.

A 60-year-old male patient visited the Oriental Medicine Research Institute of the Kitasato on ***** because of abdominal discomfort. Hangeshashin-to was administered to him and the abdominal discomfort was relieved. He continued to take Hangeshashin-to from June to August 1997. He had chills, high fever, and fatigue from ********. He stopped Hangeshashin-to and took Shosaiko-to for five days because of liver dysfunction. He was admitted to our hospital on ********. Antibiotics and stronger neo-minophagen C were administered to him. A chest roentgenogram revealed a ground-glass shadow on the left upper lung, and Shosaiko-to was discontinued. The patient began to complain of dyspnea and had fine crackles on the chest. A chest roentgenogram and chest CT showed interstitial pneumonitis. Oral predonisolone therapy was started for hypoxemia and the patient improved. A drug lymphocytes stimulation test revealed that lymphocytes were stimulated by Shosaiko-to and its components, Saiko and Ogon. A chest roentgenogram just before ingesting Hangeshashin-to revealed the interstitial change of the lung. Taken all together, this patient suffered from druginduced hepatitis and pneumonitis as a result of ingesting Hangeshashin-to and Shosaiko-to.

Combination of retrospective and prospective study.

Methods: This study prospectively examined nine T-OPLL patients who underwent posterior thoracic decompression with kyphosis correction and instrumented fusion at Hamamatsu University School of Medicine between 2017 and 2019. All underwent preoperative selective angiography to detect and evaluate the Adamkiewicz artery and ASA. Intraoperative neuromonitoring and Doppler ultrasonography were performed to analyze neurological complications and spinal cord blood flow. Results: All nine patients showed ASA stenosis in the area of T-OPLL. In all patients, the Adamkiewicz artery was located between T7 and L2 and the area of ASA stenosis corresponded to the level of T-OPLL and greatest spinal cord compression; intraoperative Doppler ultrasonography confirmed the ASA defect at the same spinal level. The number of spinal levels from the Adamkiewicz artery to the most compressive OPLL lesion was greater in the two patients who developed postoperative neurological deficit compared to those who did not (5.5 vs. 2.3, p=0.014). Conclusions This is the first study to report detection of ASA stenosis in patients with T-OPLL. Maintaining spinal cord blood flow is important in these patients to avoid neurological deterioration.