We report a case of emergent redo-mitral valve replacement during pregnancy at 23 week and 4 days of gestation. A 23-year-old woman, who underwent mitral valve replacement with a bioprosthetic valve (Carpentier-Edwards Perimount^® 27 mm) for infective endocarditis 5 years ago, was transferred to our hospital due to severe congestive heart failure. Echocardiography revealed structural valve deterioration of the mitral prosthesis and severe mitral stenosis. Emergent redo-mitral valve replacement with a bioprosthetic valve was performed to save the patient with top priority. Cardiopulmonary bypass was operated under normothermic, high flow, high pressure and pulsatile fashion. Fetal heart rate was continuously monitored during the operation. Although her baby was delivered vaginally just after operation weighing only 520 g, she was treated by the neonatologists successfully.

In coronary artery bypass grafting (CABG), a portable suction unit was used in the superior mediastinum to evaluate whether it is effective in decreasing the amount of mediastinal hematoma and the incidence of hematoma-related postoperative complications. Out of 179 consecutive patients who underwent CABG at the Matsuyama Red Cross Hospital, in 97 patients (Group 1), two drainage tubes were placed as usual in the inferior mediastinum, while in 82 patients (Group 2), a small drainage tube of the portable suction unit was additionally placed in the superior mediastinum. The total amount of postoperative drainage in Group 2 was larger than that in Group 1 but there was no statistically significant difference. The postoperative mediastinothoracic ratio expressed in comparison with the preoperative value was 134±22% in Group 1 and 123±15% in Group 2 on the first postoperative day (POD), and 133±20% and 122±14%, respectively on the seventh POD (p<0.001). Regarding postoperative complications, there were two cases of mediastinitis and five cases of late cardiac tamponade in Group 1 but none in Group 2. The difference in the incidence of these complications between the two groups was statistically significant (p<0.02). We conclude that the portable suction unit effectively decreased the amount of mediastinal hematomas and the incidence of mediastinitis and cardiac tamponade following CABG.

We evaluated risk factors for prolonged pleural effusion after surgery in 35 children who underwent total cavopulmonary connection (TCPC). Duration of their chest tube drainage was 5.4±7.0 days (1-41, median 3). In univariate analysis, significant risk factors for prolonged pleural drainage over 7 days were preoperative body weight (p=0.03), preoperative cardiothoracic ratio (p=0.03), cardiopulmonary bypass (CPB) time (p=0.02), homologous blood transfusion (p=0.03), serum protein concentration at CPB weaning (p=0.04), central venous pressure (CVP) averaged during 3 postoperative days (p=0.01) and body weight change during 3 postoperative days (p=0.01). However multivariate analysis showed only CVP averaged during 3 postoperative days was a significant risk factor for prolonged chest tube drainage (p=0.03, odd's ratio 3.3). In conclusion, to keep the central venous pressure as low as possible during the early postoperative period might decrease the duration of pleural drainage.

We experienced 6 cases of intractable perioperative myocardial ischemia with coronary spasm that was successfully treated with fasudil, a Rho-kinase inhibitor. Three of the patients (aged 49-81 years) showed ST elevation on electrocardiograms and abrupt circulatory collapse after off-pump coronary artery bypass grafting. Emergeny coronary angiogram revealed severe spasm of their own coronary arteries and/or bypass grafts. Since intracoronary and/or intragraft injection of isosorbide dinitrate (ISDN) was ineffective, we administered fasudil into the spastic vessels, and that completely resolved the spasm. The other 3 patients (aged 55-77 years) suffered myocardial ischemia during the operation, though intravenous vasodilators including ISDN, diltiazem and nicorandil had been administered continuously. Their ischemia occurred when the aorta was declamped, the pericardium opened, or the bypass graft was anastomosed, respectively. We decided to use fasudil in these cases since ISDN was ineffective, or severe spasm was found on intraoperative inspection. Administration of fasudil successfully relieved the ischemia, and subsequently all 3 patients could be weaned from the cardiopulmonary bypass during the operation. Fasudil completely resolved the myocardial ischemia in all 6 patients. In conclusion, fasudil, a Rho-kinase inhibitor, is a useful agent for perioperative myocardial ischemia including coronary spasm that is resistant to intensive conventional vasodilator therapy. We should administer fasudil and relieve spasms as early as possible to rescue patients with intractable ischemia.

A 37-year-old man presented with extensive myocardial infarction due to total occlusion of the left main trunk, complicated with near-fatal heart failure. An extracorporeal left ventricular assisted system LVAS (NIPRO-Toyobo LVAS) was implanted in our hospital. Although his postoperative course was relatively good, acute cholecystitis occurred on the 31st postoperative day, and emergeney cholecystectomy was indicated. His PT-INR was 4.13 because of taking Warfarin orally, and the cannulas of LVAS passed through his skin at the subxiphoid region. Therefore, we preoperatively transfused fresh frozen plasma quickly to reverse the PT-INR (approximately 2.0) and performed open cholecystectomy via the right side of the para-rectus abdominal muscle. His postoperative course was uneventful, and he is waiting for heart transplantation in our hospital.

Bleeding control during aortic surgery is one of the most important issue. The well-known fibrinogen-based hemostat contains the blood product, which means the potential risk of the blood-related infection. Recently, the newly-designed hemostat “Hydrofit”, which is assembled with urethane-based polymer without blood product (Matsudyte : Sanyo-chemical industry, Kyoto, Japan). Hydrofit is applicated for the hemostasis of thoracic aortic surgery. In sealing of the Hydrofit gel to the anastomosis site of aorta, water-contact initiation boosts the chemical change to the forming elastomer and adheres around anastomosis site rapidly. We experienced the extirpation of the Hydrofit which was used over 4 years ago. The patient is 42 year-old female who was operated aortic valve replacement and graft replacement of ascending aorta using a Hydrofit as a hemostat at 4 year 8 months ago due to the aortitis syndrome. Re-sternotomy and re-AVR was performed because of the prosthetic valve dehiscence due to the active aortitis syndrome. Hydrofit left around suture line without infection, and functioned very well as the elastic sealant for the long-term period.