A 79-year-old woman with angina pectoris was admitted to our institution. Coronary angiography revealed triple vessel disease. The patient had giant gastric varices 30mm in diameter and also had liver cirrhosis (Child-Pugh classification grade A). To prevent perioperative bleeding complications, we selected and performed off-pump coronary artery bypass grafting (RITA-LAD#8, LITA-LCx#14, Ao-RA-#4AV). She was discharged on the 12th postoperative day without any complications.

A 70-year-old patient underwent modified maze procedure and mitral repair including quadrangular resection, annular plication (Reed procedure), and flexible ring annuloplasty with Cosgrove ring. Systolic anterior motion (SAM) of the anterior mitral leaflet and mild mitral regurgitation was observed on weaning from cardiopulmonary bypass. The patient was medically treated, and postoperative echocardiography revealed disappearance of the SAM 11 days after surgery. In addition to the surgical condition of rather excessive annular plication and small ring, transient conditions including inotropic support, insufficient volume under diastolic dysfunction of left ventricle, and loss of atrial contraction were thought to be the causes of SAM.

Objective : To investigate the efficacy of aortic valve replacement with annular enlargement for congenital aortic valve stenosis. Methods : Eleven patients underwent aortic valve replacement with annular enlargement for congenital aortic valve stenosis in our institute between January 2002 and July 2012. The clinical status of these patients, including preoperative and postoperative echocardiography, was evaluated in this study. Results : The median age of the patients was 15.5 years (range : 9-38 years). The patients had a mean body surface area of 1.48±0.3 m² (range : 1.00-1.92 m²). Mechanical prostheses were used in all patients and the techniques of aortic annular enlargement were the Nick procedure in 4 patients, Manouguian procedure in 3 (modified Manouguian in 2), Yamaguchi procedure in 2, and Konno procedure in 2. The average follow-up period was 32.1 months (range : 1-117 months). There was neither operative death nor late death. The peak/mean pressure gradient of aortic valve improved from 77.9±31.7/46.6±18.0 mmHg preoperatively to 27.9±7.7/14.8±4.7 mmHg postoperatively and to 28.3±11.1/14.1±7.0 mmHg at intermediate-term follow-up. The estimated left ventricular mass also improved from 206.8±93.4 g preoperatively to 179.7±61.1 g postoperatively and to 100.4±76.3 g at intermediate-term follow-up, respectively. Conclusions : Our series shows the efficacy and safety of aortic valve replacement with annular enlargement for congenital aortic valve stenosis.

Cardiac operations involving cardiopulmonary bypass can cause a systemic inflammatory response such as elevation of inflammatory cytokines, which can cause organ failure. We investigated cytokine production and its inhibition by ulinastatine in patients undergoing elective coronary artery bypass grafting under cardiopulmonary bypass. Thirty-three patients received either ulinastatine (300, 000 units, intracoronary artery injection immediately after aortic closs-clamping, UTI group, n=16) or no ulinastatine (control group, n=17). Arterial blood samples were obtained at aortic closs-clamping, 5 minutes after aortic declamping, and 6, 12 and 18 hours after surgery and there were assayed for interleukin-6 (IL-6), interleukin-8 (IL-8), and polymorphonuclear leukocyte elastase (PMNE). In addition, we examined liver function (GOT, GPT, and total bilirubin), renal function (blood urea nitrogen and serum creatinine), and oxygenatory function (PaO₂/FIO₂) postoperatively. IL-8 levels at 5 minutes after aortic declamping and maximum IL-8 levels were significantly lower in the UTI group than in the control group (25.5±12.8 vs. 47.8±38.9pg/dl, p<0.05, and 28.6±13.2 vs. 58.4±40.0pg/dl, p<0.05). Blood urea nitrogen on the second post operative day (POD) and three POD and creatinine on the second POD were also significantly lower in the UTI group than the control group. Furthermore, IL-8 and PMNE levels significantly correlated positively with blood urea nitrogen and creatinine. There was significant negative correlation between IL-8 and oxygenatory function. These results shows that the ulinastatine can inhibit IL-8 levels following cardiac surgery. To combat the increase of inflammatory cytokines such as IL-8 after cardiopulmonary bypass, the ulinastatine should be used for anticytokine therapy to protect the kidneys, lungs, and other organs, and thereby decrease the risk of complications.

A 74-year-old woman presented with shortness of breath. Cardiac ultrasonography showed that left-ventricular-wall motion was good (left ventricular ejection fraction, 70.2%). The left atrium and ventricle were enlarged (left anterior dimension, 53.4mm; left ventricular enddiastolic dimension, 58.5mm). The posterior cusp of the mitral valve was thickened; the flexibility was decreased. Color Doppler ultrasonography revealed a regurgitant jet toward the posterior cusp of the left atrium. However, there was no deviation of the anterior cusp. Severe mitral-valve insufficiency was diagnosed, and surgery was performed. The second heart sound (P2) of the posterior cusp was shortened because of localized calcification of the posterior mitral annulus. This site may have caused the regurgitation. Mitral annuloplasty with rectangular resection of the valve cusps and annulorrhaphy was performed. The patient had an uneventful recovery after surgery. Postoperative cardiac ultrasonography showed that mitral-valve insufficiency had improved and was regarded as trivial. Mitral annuloplasty is generally considered unsuitable for mitral-valve insufficiency with calcification of the valve annulus. In patients such as the present case who have localized calcification, however, mitral annuloplasty can be performed by resection of the valve cusps with annulorrhaphy.