We report the successful treatment of an 81-year-old woman after a difficult diagnosis of mitral valve regurgitation resulting from partial rupture of the posterior papillary muscle. The patient, with a chief complaint of dyspnea, was admitted to our hospital in October, 2010. Echocardiography revealed severe MR and an oscillating abnormal mass attached to the mitral posterior leaflet was assessed as vegetation. Her general condition worsened and coronary angiography revealed 90% stenosis at #6 and 99% stenosis at #12. Partial papillary muscle rupture of post acute myocardial infarction was ruled out. Urgent surgery was performed. It is found that tissue we had assessed as vegetation was a part of the posterior papillary muscle with no signs of infection. MVP with quadrangular resection (P3), annuloplasty and CABG (LITA-LAD, SVG-OM) was performed. The patient was discharged on the 28th postoperative day. Echocardiography showed no MR for four years after the surgery.

Vertebral osteomyelitis (VO) is a relatively rare, but lethal, complication of infective endocarditis (IE). We report two cases who had been given a diagnosis of IE during conservative therapy for VO. A 60-year-old and a 52-year-old men each suffered onset of severe back pain. Magnetic resonance imaging demonstrated osteomyelitis in the lumbar spine. IE was revealed from congestive heart failure and persistent fever, as an unusual complication of VO. A series of echocardiograms demonstrated the progression of valvular lesions and vegetation, despite treatment with antibiotics. We therefore performed surgery. One underwent aortic and mitral valve replacement, and the other underwent aortic valve replacement. VO was treated with long-term antibiotics and good responses were achieved in both patients. The possibility of VO in the lumbar spine should be considered in patients with IE complaining of severe back pain. Appropriate antibiotic therapy over a prolonged period is recommended.

We report a rare case of primary cardiac undifferentiated pleomorphic sarcoma with invasion to the posterior mediastinum, for which partial resection of the tumor in the left atrium had already been carried out twice. After remission for about three years, recurrence in the atrial wall involving the mitral valve posterior leaflet required a third surgical resection following mitral valve replacement.

The aim of this study was to evaluate the Enclose II anastomosis device (Novare Surgical System, Inc., Cupertino, CA). A retrospective record review was conducted of all cases which underwent off-pump coronary artery bypass surgery (OPCAB) at our general hospital between January 2002 and December 2006. We identified 91 patients (a mean age of 71.0 years, the average number of distal anastomoses 2.5/patient) underwent OPCAB. The proximal anastomoses were constructed with the Enclose II (group E, 40 patients), aorta side-clamp technique (group S, 17 patients), and aorta no touch (group N, 34 patients). Group E had more grafts than group N (E:N=2.7:1.7/patient, p<0.0001), while Group E (3.1/patient) had more distal anastomoses than group S (2.6/patient, p=0.0486) and N (1.8/patient, p<0.0001). There was no difference of graft patency in each group (early; E:S:N=99.1%:97.8%:98.0%, 1-year; E:S:N=95.8%:91.3%:95.2%). There was no patient with sustained permanent neurologic deficits after OPCAB. The Novare Enclose II proximal anastomotic device appears to be a safe and effective tool during OPCAB.

Acute respiratory failure after cardiopulmonary bypass is a severe postoperative complication. We evaluated the effects of a specific neutrophil elastase inhibitor, sivelestat sodium hydrate (Ono Pharma Co. Ltd., Osaka, Japan), on postoperative respiratory failure due to acute aortic dissection (type A, AAD). A retrospective review of clinical records was conducted for all cases of emergency surgery for AAD at Ome Municipal General Hospital between June 2001 and August 2006. We identified 16 patients (median age, 64.9 years old; male: female ratio, 4:12) who had an initial postoperative PaO₂/FIO₂ of less than 300mmHg. Among these patients, 11 treated with sivelestat were compared with 5 (the control group) who did not receive sivelestat. There were no significant differences in age, body weight, sex, operating time, cardiopulmonary time, blood transfusion, initial WBC and CRP between the two groups. At arrival in the ICU, the patients in the sivelestat group had a worse respiratory condition based on parameters such as PaO₂/FiO₂ (sivelestat vs. control, 74.1 vs. 181.1mmHg, p=0.0007), A-aDO₂ (sivelestat vs. control, 620.3 vs. 556.7mmHg, p=0.0003), and respiratory index (sivelestat vs. control, 9.29 vs. 4.92, p=0.0002). However, the patients in the sivelestat group showed a greater improvement in these parameters and CRP over a 3-day observation period, compared to those in the control group. We conclude that sivelestat may attenuate postoperative respiratory complications in patients with AAD.

A 68-year-old woman with a chief complaint of dyspnea was admitted in March, 2007. She had undergone percutaneous angioplasty of the right coronary artery in 2002. Elective surgery was advised because echocardiography, left ventricular cineangiography and 64-multidetector-row CT (64MDCT) had revealed a left ventricular aneurysm (LVA), a ventricular septal perforation (VSP) through the aneurysm, and three diseased coronary arteries. The aneurysm wall was located on the inferior wall, and this was incised longitudinally. The VSP was directly sutured using 4-0 polypropylene, and the aneurysm was closed with large patches, and pledgetted mattress and running sutures. The postoperative course was uneventful, and the patient was discharged on the 13th postoperative day. It is rare for LVA and VSP to be diagnosed simultaneously, but the risk of pseudo-false aneurysm of the left ventricle is high because of free wall rupture and septal wall perforation, and therefore surgical repair is recommended.

A 85-year-old man with an abnormal shadow on X-ray was given a diagnosis of aortic arch aneurysm by CT scan. Preoperative additional careful examinations revealed that his dominant vertebral artery was the left one and he had an allergy to metals such as platinum, tin and zinc. He underwent thoracic endovascular aortic repair (TEVAR) after revascularization of left vertebral artery by bypass grafting between bilateral axillary arteries and the left common carotid artery with a T-shape graft. Because of the position of the origin of the left vertebral artery from the left subclavian artery was comparatively proximal part, we made it transposition more distally to occlude the LSA by ligation. We selected conformable GORE® TAG® for zone-1 TEVAR because the stent graft, which was not composed of allergic metals, contained only less allergic metals than any other devices commercially available. More than two years have passed since his discharge and he was followed as an outpatient without any allergic symptom and other remarkable complications. Here, we report a rare case of 2 debranching TEVAR for aortic arch aneurysm with metal allergy.