A 32-year-old woman with Marfan's syndrome who had had a heart murmur in childhood was admitted due to congestive heart failure. Her echocardiography showed anterior and posterior leaflet prolapse of the mitral valve, and also severe mitral valve regurgitation. Her chest CT scan showed no evidence of an enlarged ascending aorta. We performed mitral valve replacement using a mechanical valve, because the long-term results of mitral valve repair for Marfan's syndrome are unknown. We reviewed the literature for other examples of this rare adult case with isolated mitral regurgitation associated with Marfan's syndrome.

Reoperations after operations for acute type A aortic dissection were performed in two cases under deep hypothermic circulatory arrest. In case 1, the aortic arch replacement was performed with an inclusion technique seven years ago. The reason for reoperation was the leak from the suture lines of all anastomosis sites. Three sites of leak were closed putting sutures with pledgets. In case 2 the graft replacement of the ascending aorta was performed five years ago. The reason for reoperation was the persistent dissection from the aortic arch to the thoracic descending aorta due to the new entry formation at the site of the aortic clamp. At first the graft replacement of the thoracic descending aorta was performed, followed by arch replacement. As these conditions are preventable, we should perform the open distal anastomosis technique without using a clamp and graft replacement of aortic arch with the branched graft. Moreover, deep hypothermic circulatory arrest may appear to be a valuable adjunct for reoperation after operation on acute type A dissection.

A 46-year-old man who developed fever and general fatigue was referred to our hospital with suspicion of infective endocarditis. A ventricular septal defect had been previously diagnosed. Transthoracic echocardiography revealed vegetation on the aortic, mitral, and pulmonary valves, and each valve had significant regurgitation. An emergency operation was performed because of congestive heart failure. The aortic and mitral valves were replaced with mechanical valves. The pulmonary valve was repaired ; the anterior leaflet was resected and replaced by glutaraldehyde-treated autologous pericardium. The patient's postoperative course was uneventful. Recurrence of infection was not observed for 3 years after the operation. Triple-valve endocarditis, especially that involving a combination of the aortic, mitral, and pulmonary valves, is rare. Involvement of multiple valves on both sides of the heart may be attributed to a congenital intracardiac shunt. Early surgical intervention may be useful to control infection and heart failure, as in the present case.

A 78-year-old woman who had undergone an axillobifemoral artery bypass with a prosthetic graft for Leriche syndrome presented 1 month later with cough and fever. A clinical examination revealed obvious redness in the right groin. Routine laboratory tests uncovered inflammation and methicillin-sensitive-Staphylococcus aureus was cultured from blood samples. Mitral valve vegetations were identified by echocardiography, and after a diagnosis of infective endocarditis, specific intravenous antibiotics were immediately administered. One month later, CT revealed a large pseudoaneurysm of the posterior left ventricular wall that had not been present at the time of admission. Transesophageal echocardiography and magnetic resonance imaging showed an aneurysmal cavity arising from the wall just below the posterior mitral valve leaflet. The patient agreed to undergo cardiac surgery due to the high likelihood that the pseudoaneurysm would rupture. The mitral annulus and leaflet were normal at surgery. We resected the posterior leaflet, closed the cavity using a Xenomedica patch, and reconstructed the leaflet. We did not remove the pseudoaneurysm using an extracardiac approach because the likelihood of damaging the coronary arteries and the coronary sinus was quite high. The postoperative course was uneventful. At follow-up 1 year later, the patient was afebrile and both CT and echocardiography showed that the cavity was completely filled by the thrombus. The imaging findings were useful in determining the surgical approach.

Background : This study was performed to evaluate surgical outcomes after cardiovascular surgery (including urgent surgery) in patients 85 or older. Methods : A retrospective analysis was performed on 39 patients (mean age, 86.3 years ; age range, 85-90 years) who underwent total arch replacement (n=4), ascending aorta replacement (n=4), descending aorta replacement (n=1), aortic valve replacement (AVR ; n=13), mitral valve replacement or valvuloplasty (n=3), coronary artery bypass grafting (CABG ; n=9), CABG+AVR (n=4), tumor resection (n=1) between June 2008 and December 2012 at Dokkyo Medical University Hospital. Results : Six hospital deaths occurred. One patient died due to bleeding from a ruptured descending thoracic aortic aneurysm, and another patient died due to gastrointestinal perforation from non-occlusive mesenteric ischemia (NOMI) after urgent AVR. The other deaths were related to various complications, including lung cancer, cholecystitis, myocardial infarction, and Takotsubo cardiomyopathy, during the postoperative period. Overall 30-day mortality was 2.6%, hospital mortality was 12.8%, duration of hospital stay after surgery was 41.3 days, duration of intensive care unit (ICU) stay was 3.8 days and ventilator time was 49.1 h. Twenty patients underwent elective surgery, and 19 patients underwent urgent surgery. The two groups had similar preoperative characteristics, except for the number of patients with aortic disease. No significant difference was evident in hospital mortality (26.3% vs. 5%, p=0.065) or 30-day mortality (0% vs. 5.3%, p=0.3) when comparing the two groups. However, the duration of hospital stay (58.9 days vs. 27.5 days, p=0.049), ICU stay (6.74 days vs. 1.05 days, p=0.002) and ventilator time (89.9 h vs. 8.2 h, p=0.006) was significantly longer in the urgent surgery group than in the elective surgery group. Fourteen patients (70%) in the elective surgery group and four patients (21.1%) in the urgent surgery group were able to be discharged from the hospital to their homes within 30 days after surgery. These data demonstrated that cardiovascular surgery in patients 85 years of age or older was associated with satisfactory outcomes, and outcomes associated with elective surgery were even better than those associated with urgent surgery. Conclusions : Therefore, advanced age does not represent a contraindication of conventional cardiovascular surgery. Rather, the decision for surgery should take the patient's preoperative condition, the severity of concurrent medical disease, the wishes of the patient, and the predicted functional outcomes into account.

BACKGROUND: Predictive factors for the efficacy of dipeptidyl peptidase-4 (DPP-4) inhibitors for lowering glycosylated hemoglobin (HbA1c) remain unclear in patients with type 2 diabetes mellitus. The aim of this study is therefore to clarify predictive factors of the efficacy of DPP-4 inhibitors for lowering HbA1c after 12 months of treatment. METHODS: A total of 191 consecutive type 2 diabetic patients (male sex 55%, mean age, 68.3+/-35.8 years), who had been treated with DPP-4 inhibitors for 12 months, were enrolled in this study and evaluated retrospectively. RESULTS: After 12 months of DPP-4 inhibitor treatment, random blood glucose level, and HbA1c level, decreased from 167+/-63 to 151+/-49 mg/dL (P<0.01), and from 7.5%+/-1.3% to 6.9%+/-0.9% (P<0.01) respectively, without severe side effects. Multiple regression analysis showed that predictors of DPP-4 inhibitor treatment efficacy in lowering HbA1c level after 12 months were a decrease in HbA1c level after 3 months of treatment, a high baseline HbA1c level, a low baseline body mass index, and the absence of coronary artery disease. CONCLUSION: Most suitable candidates for treatment with DPP-4 inhibitors are diabetics who are not obese and do not have coronary artery disease. In addition, long-term efficacy of DPP-4 inhibitors can be predicted by decrement of HbA1c after 3 months of treatment.
Blood Glucose ; Body Mass Index ; Coronary Artery Disease ; Diabetes Mellitus ; Diabetes Mellitus, Type 2* ; Dipeptidyl-Peptidase IV Inhibitors ; Hemoglobin A, Glycosylated ; Humans ; Retrospective Studies ; Treatment Outcome

Right sided infective endocarditis (RSIE) is uncommon. Patients are traditionally treated with antibiotics alone, and indications for operation are not clearly established. A 23-years-old man who developed fever and general fatigue was referred to our hospital on the suspicion of RSIE. A ventricular septal defect (VSD) and untreated dental caries had been previously diagnosed. Transthoracic echocardiography revealed vegetation on the tricuspid valve and severe regurgitation. The tricuspid valve was repaired ; the anterosuperior leaflet was partially resected and repaired with fresh autologous pericardium and the use of synthetic chordae. Recurrence of infection and tricuspid valve regurgitation were not observed for 1 year after this operation.

The case is that of a 90-years-old man. A previous doctor performed abdominal graft replacement for an abdominal aortic aneurysm 5 years earlier and continued outpatient CT follow-up. Follow-up CT showed the right aortic arch and dilation of the thoracic aortic aneurysm, and the patient was referred to our hospital. Contrast-enhanced CT showed an aortic arch aneurysm ; the aneurysm diameter was 62 mm in major axis and 60 mm in minor axis, which was judged to be suitable for surgery. It was a rare right-sided aortic arch with no congenital heart malformation and no situs inversus. Endovascular treatment was considered because he was 90 years old and very elderly, but there were concerns about the risk of embolism, irregular manipulation and central landing. For the surgical method, we selected total arch replacement using a frozen elephant trunk technique. We succeeded in avoiding serious complications by selecting an appropriate treatment method through careful evaluation.

Patient: A 74-year-old man. Previous history: Total arch replacement for thoracic aortic aneurysm at 72 years old. History of current condition: The patient presented at a local otolaryngology clinic complaining of hoarseness of the voice. Left vocal cord paralysis was present, and as he had previously undergone thoracic vascular graft replacement, he was referred to our department. Further investigation with computed tomography (CT) revealed air in the mediastinum, and he was admitted for treatment of mediastinitis. Post-admission course: Upper gastrointestinal endoscopy revealed esophageal ulceration. After antibiotic treatment, thoracic subtotal esophagectomy via right thoracotomy, esophagostomy, and gastrostomy were performed on admission day 39. Vascular graft infection was also suspected, and antibiotic treatment was therefore continued. As some improvement in inflammatory response was evident, antibiotic treatment was discontinued and the patient's condition was monitored, but fever developed on day 107, and CT again revealed air in the mediastinum. Bronchoscopy revealed a broncho-mediastinal fistula in the left main bronchus. On day 110, repeated total arch replacement using a vascular graft, omentoplasty, and left main bronchus repair were performed via left thoracotomy. Esophageal reconstruction was left for later surgery, but follow-up CT on day 160 again revealed air in the mediastinum. Bronchoscopy was performed the same day and revealed a broncho-mediastinal fistula in the left main bronchus, located on distally from the previous fistula. This fistula was surgically closed on day 173. The subsequent course was favorable, and antethoracic esophageal reconstruction by jejunal elevation was performed on day 233. The patient was able to start eating on day 244, and was discharged in an improved condition on day 250.

Valsalva sinus aneurysm (VSA) is a rare disease, especially that of Konno classification Type IV. When VSA ruptures, the patient has uncontrollable congestive heart failure because of massive left-right shunt. We encountered two cases with ruptured VSA of the right atrium. Case 1 : A 71-years-old man with a ruptured noncoronary VAS complained of dyspnea on effort. He underwent surgical treatment consisting of aneurysm resection and patch closure with Hemashield after medical treatment for congestive heart failure. He progressed well after operation and was discharged on the 14th postoperative day in stable condition. Case 2 : A 41-year-old man had heard systolic murmur. We diagnosed VSA rupture with echocardiography. He was symptomless but his left ventricle diastolic diameter was dilatated and Qp/Qs was 2.0 by blood gas sampling. He underwent elective surgical treatment consisting of aneurysm resection and patch closure with Hemashield. He was discharged on the 14th postoperative day in stable condition.