A 28-year-old woman with patent foramen ovale who developed tricuspid valve infective endocarditis with complications of multiple infarctions and abscesses was treated surgically. The patient was transferred to our institution because of fever and joint pain. Echocardiography revealed a large vegetation (25 mm) on the tricuspid valve and a patent foramen ovale. Computed tomography and magnetic resonance imaging showed cerebral infarctions, multiple lung abscesses, and vertebral osteomyelitis. Staphylococcus epidermidis was identified in blood cultures. After treatment with adequate antibiotics for 5 weeks, the patient underwent surgical resection of the vegetation followed by tricuspid valve repair and direct closure of the patent foramen ovale. Antibiotic therapy was continued postoperatively, and the patient was discharged 7 weeks after the operation. No further endocarditis or embolism has occurred. In cases of right-sided endocarditis with systemic embolism and abscesses, the presence of a patent foramen ovale should be considered, and appropriate timing of the operation should be determined to prevent further systemic embolization of the vegetation.

From March 1981 to March 1990, 61 patients with Stanford type B acute aortic dissection were initially treated by conservative therapy. Among these 61 patients, the dissected lumen became occluded due to thrombosis early after diagnosis in 25 patients (Group T) and remained patent in 36 patients (Group P). Twentythree patients in Group T (92%) and 22 patients in Group P (61%) were discharged without major complications related to acute aortic dissection. However, 2 patients in Group T (8%) and 14 patients in Group P (39%) required additional surgical therapy or died during hospitalization. The mean aortic diameter at the time of admission in Group T was smaller than that of Group P (38±3mm vs 43±7mm, p<0.05). During the observation period, there was a tendency for the diameter of the dissected aorta in Group T to decrease, but to increase in Group P. Long-term survival appeared to be better in Group T than in Group P, but there was no significant difference in the overall survival curve. Large aortic diameter at the time of admission and the presence of a true thoracic aortic aneurysm were major contributing factors influencing the prognosis. A long-term follow-up study showed that the dissected lumen reduced or disappeared in 14 of 23 patients in Group T (61%) but only 2 of 16 patients in Group P (12.5%). We concluded that the patients with small dissected aortas and thrombosed dissected lumens (Group T) can recuperate only with conservative therapy. However, patients with large dissected aortas and patent dissected lumen (Group P) may require surgical therapy even in Stanford type B aortic dissection.

This study investigated whether significant coronary artery stenosis in 231 consecutive unstable angina patients can be diagnosed by thoroughgoing history-taking initial electorocardiography and symptom- or sign-limited treadmill exercise ECG after medication. The unstable angina patients were divided into those with accelerated angina, those with new-onset effort angina and those with angina at rest based on the findings of detailed inquiry. Initial ECG showed that the sensitivity and specificity of detecting significant coronary artery stenosis in all patients were 55.2% and 63.2%, respectively. In accelerated angina, sensitivity and specificity were 52.2% and 50.0%, respectively. In new-onset effort angina, sensitivity and specificity were 46.7% and 57.1%, respectively. In angina at rest, sensitivity and specificity were 69.0% and 68.3%, respectively. Initial ECG provided valuable diagnostic information about angina at rest. Treadmill exercise ECG offered 66.0% sensitivity and 89.2% specificity in all patients, respectively. In accelerated angina, sensitivity and specificity were 80.0% and 66.7%, respectively. In new-onset effort angina, sensitivity and specificity were 70.8% and 87.8%, respectively. In angina at rest, sensitivity and specificity were 48.3% and 91.4%, respectively. Thus, treadmill exercise electrocardiograms provided valuable diagnostic information in the case of unstable angina, especially accelerated angina and new-onset effort angina. For patients with angina at rest, this testing was very useful for excluding significant coronary artery stenosis.
In conclusion, detailed inquiry, initial ECG and symptom- or sign-limited treadmill exercise ECG after medical stabilization proved to be of great value for diagnosing unstable angina patients with significant coronary artery stenosis.

Constrictive pericarditis after open heart surgery is a rare entity that is difficult to diagnose. There are various approaches in the surgical treatment of pericarditis. We performed a pericardiectomy on cardiopulmonary bypass via a median approach with good results. A 67-year-old man underwent mitral valve repair in 2005. He began to experience easy fatigability as well as leg edema beginning in January 2010 for which he was treated medically. The fatigability worsened in July 2012. Echocardiography at that time was unremarkable. However, CT and MRI showed pericardial thickening adjacent to the anterior, posterior, inferior, and left lateral wall of the left ventricle. Bilateral heart catheterization revealed dip and plateau and deep X, Y waves as well as end-diastolic pressure of both chambers approximately equal to the respiratory time. He was diagnosed with constrictive pericarditis and taken to surgery. The chest was entered via median sternotomy and cardiopulmonary bypass was initiated to facilitate complete resection of the pericardium. The left phrenic nerve was visualized and care was taken to avoid damage to the structure. A part of the pericardium was strongly adherent to the epicardium. We elected to perform the waffle procedure. After pericardial resection, cardiac index improved from 1.5 l/min/m² to 2.7 l/min/m², and central venous pressure improved from 17 to 10 mmHg. Postoperatively, dip and plateau disappeared as measured via bilateral heart catheterization and diastolic failure improved. In the treatment of constrictive pericarditis, we should resect as much of the pericardium as possible. Depending on the case, this can be facilitated by median sternotomy and cardiopulmonary bypass.

Early surgical resection for cardiac myxoma is necessary because it may frequently cause cerebral infarction. However the optimal surgical timing for the disease is controversial because the acute phase of infarction may induce intracranial hemorrhage. An 82-year-old woman referred to our hospital because of unconsciousness and right hemiparesis. MRI showed infarction in the left middle cerebral artery area and UCG revealed a left atrial mass. The fourth day after the onset, brain CT showed hemorrhagic infarction and MRI showed new infarction. There was no enlargement of the hemorrhagic focus on brain CT and the patient underwent surgery on the fifth day after the onset. The postoperative course was uneventful. Despite the existence of hemorrhagic infarction, open heart surgery may save patients with cerebrovascular event.

Left ventricular thrombus is a complication of left ventricular dysfunction, including acute myocardial infarction, cardiomyopathy, and severe valvular heart disease. Surgical removal should be considered when a thrombus is mobile, when thromboembolism occurs, and when cardiac function has the potential to improve. Two patients with left ventricular thrombus underwent totally thoracoscopic transatrial thrombectomy. A thrombus developed in the apex of the left ventricle after acute myocardial infarction in one patient (Case 1) and during treatment for congestive heart failure in the other (Case 2). The minimally-invasive transatrial approach requires no sternotomy or left ventriculotomy and is thus particularly beneficial for treating left ventricular dysfunction. Moreover, totally endoscopic surgery confers the advantage of a deep and narrow visual field. Therefore, we consider that this strategy is highly effective for treating left ventricular thrombus.

A 61-year-old man underwent percutaneous coronary intervention (PCI) for the right coronary artery. However, he had an acute onset of right neck pain and swelling after PCI. Contrast enhanced computed tomography (CT) revealed extravasation into the mediastinum and aberrant right subclavian artery. After transfer to our hospital, we performed emergency endovascular repair for iatrogenic arterial injury. His postoperative course was uneventful.

A 62-year-old woman with the tetralogy of Fallot (TOF) diagnosed at 24 years of age, was admitted with fever and dyspnea. She also had cyanosis and heart failure and was categorized as New York Heart Association (NYHA) functional class IV. Echocardiography showed TOF with a-grade III tricuspid valve regurgitation. Cardiac catheterization revealed major aorto-pulmonary collateral arteries (MAPCAs) for the left upper pulmonary circulation. After coil embolization of MAPCAs to reduce abnormal intracardiac return as well as postoperative left ventricular volume overload, the patient underwent total surgical correction (i.e., right ventricular outflow tract reconstruction using Medtronic FreeStyle Valve and transannular patch, ventricular septal defect closure, and tricuspid annuloplasty). Postoperatively, the patient had a satisfactory course during the 10-year follow-up period with a grade-I NYHA classification. In conclusion, intracardiac repair of TOF in case over 60 years of age can be performed safely by preoperative MAPCAs embolization and subsequent TOF repair with a strategy to abolish pulmonary and tricuspid valve regurgitation.

Central diabetes insipidus (CDI) is a disease that caused by insufficient or no anti-diuretic hormone (ADH) secretion from the posterior pituitary, which results in an increase in urine volume. CDI is controlled with ADH supplementation thereby reducing urine output and correcting electrolyte imbalance. However, reports on perioperative management for CDI patient are scarce, especially for patients who underwent cardiac surgery. We herein report our experience of the management of a CDI patient who underwent surgery for valvular heart disease.

The case is a 72-year-old woman who developed secondary CDI after pituitary tumor removal. She had been controlled with orally administered desmopressin acetate hydrochloride. She underwent aortic valve replacement and mitral valve repair for severe aortic, and moderate mitral regurgitation. Immediately after surgery, we started vasopressin div, which yielded good urine volume control. However, once we started to switch vasopressin to oral desmopressin administration, the control became worse. We thus made a sliding scale for subcutaneous injection of vasopressin every 8 h according to the amount of urine output, which resulted in good control. Overlapping administration of vasopressin and oral desmopressin between postoperative day 12 and 17 resulted in successful transition. The patient was discharged with oral desmopressin administration. Management with sliding scale for vasopressin subcutaneous injection after surgery was useful in controlling a CDI patient who underwent major cardiac surgery.

A 37-year-old female was admitted to our hospital because of haemoptysis. She had undergone descending thoracic aorta-abdominal aorta bypass grafting 11 years previously. Then the diagnosis was atypical coarctation due to aortitis syndrome. No follow up had been continued. Angiogram and CTscan disclosed a false aneurysm at the anastomotic site of the descending thoracic aorta, which was ruptured into the left lung. An emergency operation was performed. A new extra-anatomical ascending aorta abdominal aorta bypass was constructed using 16mm Dacron prosthesis, and three permanent clamps were employed for thromboexclusion of the descending aorta, previous bypass graft and the ruptured aneurysm. At present, three years after the operation, she is leading normal life with medication of hypotensive drugs. Pathogenesis, surgical approach and long-term postoperative care were discussed.