The onset mechanism of takotsubo cardiomyopathy is unkown. The reported cases of takotsubo cardiomyopathy that happened after cardiac surgical operation were very few. We describe one case of takotsubo cardiomyopathy with left ventricular outflow tract obstruction (LVOTO) that occurred after having undergone mitral valve replacement (MVR) for combined valvular disease. The patient was an 82-year-old woman who was hospitalized with congestive heart failure in our hospital. She had diagnosis of rheumatic valvular disease (i.e. severe mitral regurgitation and mild mitral stenosis, secondary tricuspid regurgitation), atrial fibrillation and pulmonary hypertension. She had a sigmoid septum pointed out by cardiac ultrasonography. Preoperative coronary angiography was normal. After general anesthesia induction, bradycardia and hypotension developed. Therefore epinephrine and norepinephrine were administered. The rheumatic mitral valve was replaced using a 27 mm-size mitral pericardial bioprosthesis, preserving the posterior mitral leaflet. DeVega tricuspid annuloplasty and maze surgery were also performed at the same time. We did not recognize wall motion abnormalities by the transesophageal echocardiographic examination during the operation. On postoperative day 1, she was extubated and became hypotensive immediately. Takotsubo cardiomyopathy was diagnosed from characteristic views (an apical ballooning and a preserved basal contraction of the left ventricle) by transthoracic echocardiography (TTE). This echocardiogram showed also LVOTO of pressure gradient 38 mmHg. Blood transfusion and discontinuation of epinephrine infusion improved LVOTO. TTE showed a gradual recovery of the left ventricle to normal systolic function, on postoperative day 34. The postoperative coronary angiogram was normal. We presumed that LVOTO was important in the onset and severity of takotsubo cardiomyopathy. In this report, we showed also the pathological significance of the sigmoid septum.

We report a case of an 85-year-old woman with severe aortic insufficiency caused by structural valve deterioration (SVD) of Medtronic Freestyle stentless aortic bioprosthesis (Freestyle valve) complicated by rheumatic multivalvular heart disease. The patient received an aortic valve replacement by using the modified sub-coronary method with a 21 mm Freestyle stentless porcine valve (Medtronic Inc., Minneapolis, MN, USA), for severe aortic valve stenosis at of the age of 71. The patient developed severe heart failure 14.5 years after the surgery. She was admitted for severe aortic insufficiency caused by a leaflet injury (tear) of the Freestyle valve. She also had had rheumatic mitral stenosis and secondary tricuspid insufficiency with severe pulmonary hypertension. Therefore, treating her heart failure was difficult, but surgery was performed. The leaflets of the stentless bioprosthesis were resected. The insertion of the needle suture into the annulus of the stentless valve was difficult because of calcification of the tissue. An aortic root enlargement procedure was performed using a bovine pericardial patch, enabling the insertion of the needle suture into the Dacron cloth at the bottom of the stentless valve, with 2-0 Ethibond threads and single sutures. We successfully performed an aortic valve re-replacement using an Open Pivot Mechanical Heart Valve (OPHV) 16 mm AP (Medtronic, Minneapolis, MN, USA), which was implanted by using the partial valve-in-valve technique. Simultaneously, mitral valve commissurotomy and tricuspid annuloplasty were performed. The patient had an uneventful postoperative recovery.

A 78-year-old woman had been undergoing medical treatment for hypertension since she delivered a son in her early twenties. Three months previously, she was admitted with heart failure. She had felt leg fatigue for a long time, and the pressure gradient between the upper and lower limbs was about 60 mmHg. On further examinations, she was found to have an atrial septal defect (ASD), tricuspid valve regurgitation, atrial fibrillation, and severe coarctation of the aorta (CoA) with well-developed collateral arteries. We performed ASD closure, tricuspid annuloplasty with a flexible ring, left atrial maze operation and extra-anatomic bypass from the ascending to the abdominal aorta through a median sternotomy and upper median laparotomy. She had no postoperative complications and the pressure gradient between the upper and lower limbs improved remarkably postoperatively. It is rare for a patient over 70 years old who for the first time was given a diagnosis of CoA and ASD with other heart disease and who underwent surgical correction. We think one stage surgery with extra-anatomic bypass from the ascending to the abdominal aorta is a safe and effective technique for patients suffering CoA with heart disease.

Reports laparoscopic deroofing of liver cysts have drawn our attention recently. A laparoscopic approach has advantages as minimal access surgery, but has the possibility of causing complications by hemorrhage and bile leakage. In this paper, we described three surgical cases of symptomatic giant liver cysts. In case 1, hemorrhage occurred when we resected the cyst wall by electrocautery with the aid of a laparoscope. Therefore, in case 2, we resected the cyst wall with an endoscopic stapling device (ENDO GIA) for complete hemostasis and control of bile duct, because the peritoneal surface of the cyst was overlaid by thin parenchymal tissue. In case 3, we resected the cyst wall with laparoscopic coagulating shears (LCS), because the peritoneal surface of the cyst was mainly extrahepatic. This device reduces the risk of hemorrhage and damage to the liver. These patients were asymptomatic after operation and developed no signs of recurrence. We suggest that the laparoscopic deroofing of liver cysts with these devices, a simple, safe procedure, may become a primary method of treating symptomatic liver cysts.

Objective: This study aimed to examine the background and outcomes of transcatheter aortic valve replacement (TAVR) in patients with low-risk scores. Methods: We retrospectively reviewed 69 patients with risk scores of<4% undergoing TAVR in a single institution from January 2016 through June 2021. Results: The mean age of the patients was 81±4.5 years, and 52% of them were women. The reasons for TAVR selection included very old age (≥85 years; 20%); frailty (51%); ascending aortic calcification (4.3%); history of mediastinal radiation therapy (2.8%); and respiratory diseases (10%). Six patients required early discharge and recovery for another surgery following treatment of aortic stenosis or family members' care, and 2 patients had an estimated life expectancy of 1-5 years. Also, three patients strongly desired TAVR despite having none of the objective factors that favor TAVR. The median lengths of stay in the ICU and after TAVR were 1 day (1-11 days) and 5 days (3-40 days). There was neither operative mortality nor a need for aortic valve reintervention. Kaplan-Meier curves showed that the one-year survival rate was 99%, and two-year and three-year survival rates were 97% each. The causes of late death were sepsis, unknown factor, and intracranial hemorrhage. Discussion: The short-term and medium-term outcomes of TAVR with low-risk score patients were favorable although the patient background was poor due to high-risk factors for surgery that were excluded from the risk scores.