A 45-year-old woman with moderate mitral regurgitation due to mitral valve prolapse developed respiratory discomfort after cellulitis and visited our hospital. Electrocardiogram showed ST elevation in V2, V3, V4 and serum creatinine kinase was high. Transthoracic echocardiogram revealed large mitral and aortic vegetation with severe valvular regurgitation and anterior wall motion asynergy. On computed tomography and magnetic resonance imaging, splenic infarction and right renal infarction cerebral infarction on right sided frontal white matter (1 cm in diameter) was revealed. These findings led to a diagnosis of acute heart failure due to severe regurgitation and coronary artery embolism with infective endocarditis, thus we performed an emergency cardiothoracic surgery. After general anesthesia, she suffered severe hypotension despite the injection of a high dose of catecholamine, then developed persistent ventricular tachycardia. We started cardiopulmonary resuscitation, and percutaneous cardiopulmonary support. After obtaining stable hemodynamic status, we performed surgery. The intraoperative examination showed vegetation (2 cm in diameter) on each aortic cusp, large vegetation on the anterior and posterior mitral leaflet, rupture of the posterior leaflet choreae tendineae, and vegetation on the wall of the left atrium. We performed maximal possible debridement of the infected tissue. Subsequently, we performed mitral valve replacement and aortic valve replacement, tricuspid annuloplasty. We finished surgery without cardiopulmonary support. After tight control, the patient was discharged on the 52nd postoperative day. The patient showed no recurrence of infection during 9 months of follow-up. Cases of coronary embolism with infective endocarditis are rare and have high mortality, and their treatment is still controversial.

We present a case of redo aortic valve replacement (AVR) in a 71-year-old man with a Lillehei-Kaster valve implanted 42 years prior. The patient initially underwent AVR and open mitral commissurotomy procedures for aortic regurgitation complicated with mitral stenosis in 1978 at the age of 29. Thereafter, he was followed at our outpatient clinic and treated without anticoagulant therapy for the initial two decades of the postoperative period. During the long-term follow-up, the mean pressure gradient remained between 40 and 60 mmHg and there were no adverse events noted before occurrence of heart failure triggered by tachycardia and pneumonia. Following improvement of heart failure, redo AVR was performed. There was no structural damage, thrombosis, or Lillehei-Kaster valve opening restrictions, though severe pannus growth on the left ventricle side was observed, which was thought to be the cause of the increased pressure gradient. This is the first known report of redo AVR after many years in a patient who underwent Lillehei-Kaster valve implantation. Furthermore, no other study has noted findings regarding pressure gradient change during the long-term follow-up period in such cases.

A 61 year old woman who had been receiving treatment for ulcerative colitis for 14 years complained of respiratory discomfort on exertion and was diagnosed with severe mitral regurgitation due to mitral valve prolapse. Minimally invasive mitral valvuloplasty with right mini-thoracotomy was performed in our facility. Laboratory findings showed elevated levels of serum creatine kinase (CK) and CK-MB immediately after surgery. In addition to elevated levels of myocardial enzymes, ST depression was seen in an electrocardiogram on postoperative day 2 ; therefore, we suspected myocardial ischemia during the surgery. Despite the persistently elevated levels of myocardial enzymes, coronary angiography showed no significant abnormalities. Because of the possibility of false CK elevation, we performed CK electrophoresis, which revealed the presence of macro-CK type 1. CK-MB activity is often falsely elevated when determined by immune-inhibition in macro-CK patients, and that leads to the suspicion of myocardial ischemia. We considered that it may be highly difficult to identify macro-CK in a patient after cardiovascular surgery owing to elevated levels of myocardial enzymes in most such patients.