We present a surgical case of mycotic aneurysm of the ulnar artery occurring 2 months after surgical treatment for infective endocarditis (IE). A 59-year-old man was referred to our hospital because of dyspnea and fever. An echocardiogram showed severe mitral regurgitation with vegetations. Blood culture disclosed Methicillin-resistant Coagulase Negative Staphylococcus (MRCNS), and brain computed tomography (CT) demonstrated an intracranial hemorrhage in the right posterior lobe. After one month of antibiotic treatment, mitral valve replacement (MVR) was performed successfully. Antibiotic treatment was continued postoperatively for 4 weeks; the C-reactive protein (CRP) level and peripheral white blood cell count were reduced to the normal range. Two months after MVR, a pulsatile mass rapidly increasing in size was seen in his right forearm. Contrast-enhanced CT showed aneurysm formation in his right ulnar artery. The aneurysm was managed by excision, and the brachial artery was reconstructed with a reversed saphenous vein graft. It is essential when observing the course of IE patients to bear in mind at all times that a healed mycotic aneurysm might increase in size.

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 69-year-old woman suffered from postprandial abdominal pain and hematochezia. Colonoscopy suggested ischemic colitis, and intestinal angina was diagnosed by multirow-detector computed tomography (CT), which showed occlusion of the superior mesenteric artery (SMA). On enhanced CT, there was extensive calcification on the aortic wall and aortic expansion and several mural thrombi in the thoracoabdominal and abdominal aorta, as well as severe stenoses in the bilateral common iliac arteries. A bypass from the right renal artery, which was the only artery without significant stenosis of the major branches of the abdominal artery, to the SMA, was created using a saphenous vein graft. Postoperatively, the postprandial abdominal pain disappeared, and the patient was discharged after a good postoperative course.

A 65-year-old woman suffered from left-side paralysis and dysarthria after sudden chest pain, and we diagnosed cerebral infarction caused by type A acute aortic dissection in the Stanford classification. At that time, the aberrant right subclavian artery with Kommerell's diverticulum was found on enhanced computed tomography. The acute aortic dissection with closed false lumen was treated conservatively. Because the ulcer-like projection (ULP) expanded during the course, we performed surgery. Ascending aorta and arch replacement, patch closure of Kommerell's diverticulum and reconstruction of right subclavian artery were performed simultaneously. The postoperative course was good.

We present here a rare case of coronary artery bypass grafting through a left thoracotomy after substernal gastric interposition for esophageal cancer. A 58-year-old man, who had undergone esophagectomy and substernal gastric interposition 11 years previously, was admitted for cerebral infarction from which he made a good recovery without any complication. At this time, the patient was diagnosed as having coronary artery disease on electrocardiogram. Cardiac catheterization revealed triple vessel disease. Coronary artery bypass grafting to the left anterior descending artery and obtuse marginal branch through a left thoracotomy was performed using a radial artery Y-graft under femorofemoral bypass. The aorta was cross-clamped and the heart was arrested with antegrade cold cardioplegic solution for the distal anastomosis of the left anterior descending artery and the obtuse marginal branch which was embedded within the myocardium. The postoperative angiography showed good coronary flow. Left thoracotomy approach provides a good exposure of the left coronary artery. This approach, therefore, is advocated as an alternative method for cases requiring coronary artery bypass but in which median sternotomy is difficult, such as the present case. The appropriate procedure for the site of thoracotomy, supporting methods, choice of graft, and the site of graft anastomosis should be selected in each patient.

Rheumatic tricuspid stenosis has become rare recently. A 54-year-old woman had undergone mitral valve replacement with a Carpentier-Edwards bioprosthesis for mitral stenosis 22 years previously and had undergone repeat mitral valve replacement for prosthetic valve failure 10 years later. She was admitted with severe leg edema. Cardiac catheterization revealed pulmonary hypertension and tricuspid stenosis with a diastolic pressure gradient of 6mmHg across the tricuspid valve. Tricuspid valve replacement was performed with a Hancock bioprosthesis. The postoperative course was uneventful and her edema improved markedly. This case suggested that careful follow-up to detect progression of tricuspid stenosis is necessary in patients with rheumatic valve disease and pulmonary hypertension.