Absence of the right superior vena cava with persistent left superior vena cava without any other cardiac anomalies in visceroatrial situs solitus is rare. A 41-year-old man presented with a feeling of anterior chest pressure on effort. Severe mitral regurgitation due to anterior prolapse of the A2-A3 segments and moderate tricuspid regurgitation were diagnosed. Three-dimensional CT scan revealed an absent right and persistent left superior vena cava. Electrocardiographic findings showed a typical coronary sinus rhythm. At operation, a pulmonary artery catheter was placed via the right femoral vein under fluoroscopy. After starting cardiopulmonary bypass with a single venous cannula in the inferior vena cava, an L-shaped venous cannula was directly placed into the left superior vena cava. Mitral valve repair was performed, with 4 pairs of Gore-Tex CV-5 artificial chordae and mitral ring annuloplasty through a standard transverse left atriotomy. Tricuspid ring annuloplasty was also performed. His postoperative course was uneventful. Postoperative echocardiography showed only trivial mitral and tricuspid regurgitation. In patients with such venous anomalies, the area around the coronary sinus should be protected during intracardiac procedures to preserve the coronary sinus rhythm. We therefore recommend direct venous cannulation of the left superior vena cava instead of retrograde cannulation via the coronary sinus, and standard transverse left atriotomy for mitral exposure.

Infective endocarditis on an annuloplasty ring following mitral valve repair is rare. A 59-year-old man underwent emergency sextuple coronary artery bypass grafting and mitral annuloplasty with a 26mm ring for acute myocardial infarction and mitral regurgitation. Seven weeks later, he was readmitted complaining of abdominal pain and diarrhea. He experienced high-grade fever with chills associated with leukocytosis and elevation of C reactive protein after gastroduodenal endoscopy. Although antibiotics were administered intravenously for several weeks, the fever persisted. Transesophageal echocardiography revealed vegetations on the mitral annuloplasty ring. Infective endocarditis was diagnosed as the culprit of the unknown fever and urgent surgery was indicated. Following redo median sternotomy, the heart was meticulously dissected out. On cardiopulmonary bypass with the heart arrested, left atriotomy was carried on the interatrial groove. Because of the small left atrium, Dubost incision was added for better mitral valve exposure. The infected annuloplasty ring was excised with the vegetations. The mitral valve was easily repaired because the valve leaflets had minimal changes except a small perforation at the base of the posterior middle scallop. After thorough debridement of the mitral valve, a glutaraldehyde-treated autologous pericardial strip was sutured along the annulus as a posterior pericardial band. Culture of the vegetation proved negative. His postoperative course was uneventful. He has been doing well for more than two and a half years with trivial mitral regurgitation and no recurrence of infection. According to the American Heart Association guidelines, endocarditis prophylaxis is not usually needed for gastrointestinal endoscopy, but is optional for high risk patients including those with prosthetic cardiac valves. Such a diagnostic procedure should be avoided soon after the application of an annuloplasty ring and if necessary, antiinfective prophylaxis may be indicated.

A 78-year-old woman on chronic hemodialysis was found to have severe aortic stenosis causing refractory hypotension during hemodialysis and elected to undergo aortic valve replacement. However, chest CT scan revealed a totally calcified “porcelain” ascending aorta which prevented safe aortic cross-clamping. MRA also showed stenosis of the origin of the left subclavian artery. At operation, an area free from calcification was identified in the lesser curvature of the ascending aorta where an aortic cannula was placed. Cardiopulmonary bypass was commenced. A single selective cerebral perfusion was added via the left axillary artery to maintain adequate flow to the dominant left vertebral artery. The patient was cooled to a rectal temperature of 24°C when a proximal transverse aortotomy was made and an occlusion balloon was inserted into the ascending aorta during circulatory arrest for 2 min. The cardiopulmonary bypass was restarted with half systemic flow. The aortic valve was excised and a 19-mm Carpentier-Edwards bovine pericardial valve was placed in the supravalvular position with simple interrupted sutures. The body was further cooled down to 19°C. On another circulatory arrest, the balloon was removed. Endarterectomy was performed along the edges of the aortotomy which was reinforced with equine pericardial strips. The aortotomy was then closed with a running suture. The circulation was restarted and the patient was rewarmed. Circulatory arrest time was 42 min. The patient was weaned from cardiopulmonary bypass without difficulty and had an unremarkable recovery without neurologic complications. The operative technique described here for the treatment of aortic valve disease in a patient with a porcelain aorta is safer than deep hypothermic circulatory arrest alone, allowing shorter circulatory arrest period. In addition, endarterectomy of the aortotomy edges reinforced with xenopericardial strips is useful to secure the closure line against bleeding.

Horner's syndrome is a rare complication after open heart surgery via median sternotomy. To date only two cases have been reported in Japan. A 77-year-old woman presented to our hospital, complaining of worsening effort angina. She was found to have old inferior myocardial infarction, severe triple vessel diseases and ischemic mitral regurgitation. At operation, the patient was placed in the supine position with the left arm abducted to approximately 80 degrees to harvest the left radial artery. At the same time, the left internal thoracic artery was dissected free from the chest wall using a Delacroix-Chevalier retractor following median sternotomy. She underwent mitral ring annuloplasty and three coronary artery bypass graftings on cardiopulmonary bypass. Her immediate postoperative course was uneventful. On postoperative day (POD) 2, however, left Horner's syndrome became apparent with the classical triad: ptosis, miosis and enophthalmos. She subsequently complained of pain and numbness of the left arm. A chest X-ray film on POD 4 revealed posterior fracture of the left first rib, suggesting that the fracture fragments or the associated hematoma could have caused direct injury of the cervical sympathetic trunk and the brachial plexus. On POD 21, the discharge day, the neurological symptoms still persisted mildly but spontaneously resolved within 6 months. In order to prevent such complications, we should treat the sternum and the ribs with great caution when using a sternal retractor and harvesting the internal thoracic arteries.

Objective: Several studies have demonstrated the relationship betweentemporomandibular disorder (TMD) and emotional stress. Nonetheless, few surveys haveexamined the relationship between type A behavior patterns and TMD. The aim of this studywas to clarify the relationships among TMD, type A behavior patterns, bruxism, andemotional stress in Japanese undergraduate students.

Methods: This study was undertaken in Nayoro City, Japan, in 2015, amongstudents of Nayoro City University. The survey was conducted through an anonymous,self-administered, multiple-choice questionnaire. Information was gathered on itemsevaluating the extent of TMD symptoms, bruxism, type A behavior patterns, and pronenessand sensitivity to emotional stress.

Results: The questionnaire recovery rate was 31.8% (175/551). There was ahigh likelihood of TMD in 16.1% of respondents, which is comparable to the findings ofprevious surveys on Japanese high school students. In keeping with previous studies, weconfirmed significant relationships between TMD and both emotional stress and bruxism. Aweak but statistically significant association was found between TMD and type A behaviorpatterns.

Conclusion: We propose that TMD may be one of the diseases related to thetype A behavior pattern.

Anticoagulation management in cardiac surgery can be difficult in patients with heparin-induced thrombocytopenia (HIT). We report a patient who underwent reoperation of cardiopulmonary bypass (CPB) using argatroban in combination with nafamostat mesilate. A bolus of 0.25 mg/kg argatroban was administered, followed by continuous infusion of 5-10 μg/kg/min argatroban and 100 mg/h nafamostat mesilate. No complications such as thrombosis were observed during either CPB or the perioperative period. Although we used argatroban and nafamostat mesilate, which has a shorter half-life than argatroban, the anticoagulant effect was prolonged, and the patient had an uneventful postoperative course despite requiring substantial blood transfusion.

A case of intracranial hemorrhage during valve surgery for infective endocarditis is reported. The patient was a 40-year-old man whose chief complaint was fever of unknown origin. Echocardiography demonstrated severe mitral regurgitation with vegetations. A blood culture demonstrated Streptococcus salivarius. He was treated with penicillin G and gentamicin for 6 weeks. Magnetic resonance imaging (MRI) was performed 10 days before surgery, but acute infarction, hemorrhage, or mycotic aneurysm were not observed. Mitral valve replacement was performed with a mechanical valve. Postoperatively, the patient had hemiplegia. Hemorrhage was visible in the right thalamus and left cerebellum on computed tomography. Ventricular drainage and removal of the cerebellar hematoma were performed the next day. These results suggest that to avoid cerebral complications during cardiac surgery for infective endocarditis, strict activated clotting time control and MRI just before surgery appear to be necessary.

We report the findings in a 75-year-old woman who was given diagnosis of rupture of the internal thoracic artery (ITA) and was successfully treated by coil embolization. The patient suddenly felt chest pain, and a chest CT revealed a mediastinal hematoma. She was suspected to have an acute aortic dissection, and therefore transferred to our hospital. Upon careful examination, a CT showed a hematoma in the superior mediastunum and the extravasation of the left internal thoracic artery. Emergency coil embolization was thus performed to stop the bleeding. After the embolization, no further hemorrhaging was observed. The patient was uneventfully discharged in a healthy state 2 weeks later. Rupture of the internal thoracic artery is rare. However, it is important to include this potential disease in the differential diagnosis when encountering a patient presenting with an atraumatic mediastinal hematoma.

We report a case of successful surgical treatment for an aortic anastomotic false aneurysm associated with a graft-duodenal fistula after abdominal aortic aneurysm repair. A 63-year-old man was admitted with melena and an aortic anastomotic false aneurysm after prosthetic graft replacement 8 years previously. CT scan demonstrated an aneurysm with a maximum diameter of 70mm at the proximal anastomotis of the prosthetic graft. Gastroduodenoscopy revealed no bleeding site in the stomach or the first and second portions of the duodenum. Therefore, we performed an emergency operation under a diagnosis of an aortic anastomotic false aneurysm associated with a graft-duodenal fistula. The aneurysm was replaced with interposition of a new prosthetic graft via a thoracoabdominal approach. The fistula was repaired by covering the duodenum with the jejunum through a left pararectal laparotomy. The postoperative course was uneventful, and there was no evidence of graft infection at 14 months after the operation.

A 36-year-old previously healthy woman with cardiomegaly on a routine chest X-ray was given a diagnosis of primary chylopericardium after pericardial puncture revealed milky effusion. Endoscopy-assisted ligation of the thoracic duct and creation of a pericardial window was performed. The operation was greatly facilitated by the preoperative three-dimensional CT scan with lymphangiography that precisely demonstrated the distribution of the thoracic duct and other lymphatic ducts.