Studies have shown that postoperative disseminated intravascular coagulopathy (DIC) occurs in some patients with cardiac disease, acute aortic dissection, and ruptured abdominal aortic aneurysm. The specific pathophysiology of DIC in these settings are related to low cardiac function, shock, infection and sepsis as well as activation of coagulation cascade in the aneurysm sac or dissected aorta. A soluble form of recombinant human thrombomodulin (rhsTM) was approved in 2008 for the treatment of DIC. This report describes the safety and efficacy of rhsTM for the treatment of DIC in patients with cardiovascular disease operated in our department. Between October 2010 and March 2012, 35 patients with postoperative DIC were treated with rhsTM. Diagnosis of DIC was based on the diagnostic criteria for DIC of the Japanese Association for Acute Medicine (JAAM). During the first 6 months of the study period, after a diagnosis of DIC was made, the patients were treated with gabexate mesilate and antithrombin III, and if patients showed no improvement with conventional treatment, they received rhsTM for 6 days. During the last 10 months of the study period, patients received rhsTM soon after a diagnosis of DIC was made. Twenty seven patients survived for 28 days after rhsTM treatment, and the mortality rate was 22.9% (8/35). Patients who survived showed improvement in acute phase DIC scores, FDP levels, D-Dimer, fibrinogen and platelet counts during rhsTM treatment, but no improvement was observed in patients who died. No serious adverse events were found up to 28 days after the start of rhsTM administration. In conclusion, this study showed no adverse events of rhsTM, and further studies are needed to confirm that rhsTM administration is an effective therapeutic modality in the management of DIC after cardiovascular surgery.

We present the case of a 72-year-old male with Inspiris RESILIA aortic valve (Inspiris) transvalvular leakage during surgical aortic valve replacement (AVR). The patient initially underwent AVR for aortic regurgitation with a bicuspid aortic valve at the age of 64. By the age of 72, the valve had deteriorated and it was assessed that redoing the AVR was necessary. The Inspiris was inserted in the supra-annular position using the non-everting mattress suture technique with a COR-KNOT. During weaning off from cardiopulmonary bypass, transesophageal echocardiography (TEE) captured unfamiliar turbulent flows from the three stent posts. Further TEE revealed that these flows originated from the base of the stent posts, which gradually decreased and disappeared by the end of the surgery after administration of protamine. The patient has been discharged uneventfully. Paravalvular leakage has not been observed during the postoperative course and we could not find TVL in TEE 2 months postoperatively. While considering the detailed mechanism, it is possible that there is no need for re-exploration concerning three directional TVL in the Inspiris.