A 71-year-old man who had been on peritoneal dialysis for 6 years was referred to our hospital for renal transplantation from a living donor. Preoperative echocardiography revealed diffuse severe hypokinesis, a left ventricular ejection fraction (LVEF) of 25%, and a pedicled floating mass in the right atrium. He had not exhibited positive symptoms of active endocarditis or metastatic malignant tumor, and the causes of cardiomyopathy seemed to be uremic and/or ischemic factors. Renal transplantation was postponed, and the extirpation of the mass in the right atrium was scheduled. LVEF improved to 48% 2 months following the induction of hemodialysis before the cardiac operation. Pathohistological findings of the extirpated intra-atrial mass showed sphachelus and fibrotic thrombus, which meant asymptomatic healed infective endocarditis. He recovered uneventfully, and underwent a living renal transplantation from living donor 5 months after the cardiac operation. LVEF further improved better to 56%, and his performance status was remarkably improved. These results imply that renal transplantation and hemodialysis in peritoneal dialysis patients with uremic cardiomyopathy can achive improvement of cardiac function and enable a safe cardiac operation.

A 48-year-old man with Buerger disease and intractable finger ulcers underwent successful transplantation of autologous peripheral blood-derived mononuclear cells pretreated with erythropoietin and blood donation to activate bone marrow function. Clinical symptoms on his finger ulcers improved significantly within 1 month after mononuclear cell transplantation, however, one of the intractable ulcers reappeared 2 months later. In total three transplantations were performed. Every cell transplantation revealed similar effectiveness 1 month later, and the interval of the subsequent disappearance of finger ulcers ranged from 3–6 months. There were no adverse effects based on this new therapy. These findings suggest that autologous peripheral mononuclear cell transplantation pretreated with erythropoietin and blood donation might be a non-invasive and safe alternatives for patients with Buerger disease and intractable finger ulcers.

A 24-year-old woman underwent successful repair of a traumatic pseudoaneurysm of the aortic isthmus concomitant with right diaphragmatic hernia which developed after a traffic accident, and the steering wheel of the crashed car was considered responsible for both lesions. Due to the right diaphragmatic hernia, she could breathe mainly with the left lung only. The aortic isthmus aneurysm was considered to be a pseudoaneurysm, and because of the potential risk of rupture, we performed urgent aortic surgery. Prior to a left thoracotomy, we anastomosed an 8-mm prosthetic graft to the right axillary artery. When the left lung was collapsed in order to perform a femoro-femoral bypass, the SpO₂ level of her right index finger and her cerebral rSO₂ markedly decreased. Therefore, we administered additional perfusion via the right axillary artery, which provided sufficient oxygen to the upper body and brain. The patient underwent Marlex mesh reinforcement of the right diaphragmatic hernia 30 days after grafting, and is doing well 1 year postoperatively.

A 69-year-old woman had syncope and aphasia. Magnetic resonance imaging showed multiple cerebral infarctions in both hemispheres. Cardiogenic embolisms were suspected, but no arrhythmic causes were shown. Transesophageal echocardiography revealed a highly calcified mitral annulus (MAC) with a rough intraluminal surface and mild mitral regurgitation, but no thrombus or tumor in the left heart system. However, recurrent multiple cerebral embolisms occurred in spite of strict anticoagulation therapy. We speculated that spontaneous rupture of the MAC was the cause of the scattered cerebral embolisms, and we therefore planned to remove the MAC as safely as possible and to endothelialize the deficit of MAC with autologous pericardium. Operative findings revealed that the MAC in P2-P3 had ruptured longitudinally and the ostium of the left atrium was connected to the ostium of the left ventricle as an inter-atrioventricular tunnel beneath the posterior mitral annulus with a fragile calcified wall. The finding suggested that calcified particles that had peeled away from the MAC by normal heart beating resulted in the cerebral infarctions. Therefore, she underwent resection of the MAC and mitral valve replacement with reinforcement of the decalcified posterior mitral annulus between the posterior left ventricular wall and the left atrial wall using autologous pericardium, which enabled both appropriate insertion of a mechanical prosthetic valve and endothelial continuity covering the surface of the residual MAC. No systemic embolism has occurred for two and a half years after surgery. This is the first case report of cerebral embolism caused by a spontaneously ruptured MAC.

Background: Unstable sternal fixation following sternotomy is one of the risk factors that affects postoperative outcomes in cardio-thoracic surgery and is associated with increased risk of infection, bleeding and delayed rehabilitation due to pain associated with sternal movement. Sternal plate systems, which help stabilize fixation, has been limited in use due to patients' comorbidities, such as diabetes mellitus (DM) and obesity. The conventional wire sternal-fixation procedure, which depend on years of physician' experience, raise concerns such as unstable sternal fixation due to uncompleted wire twisting. Therefore, a novel sternal-fixation procedure using both titanium cable and a PLA mesh plate was investigated as a potential improvement for sternal closure. We compared the ability of this new sternum fixation procedure (group N) against the conventional sternal fixation procedure using only a wire (group O) to achieve more stable postoperative sternal fixation. Methods and Results: Among adult open-heart surgeries performed between August 2020 and April 2023, 155 patients who underwent postoperative CT were included, with group N being the combined group and group O being the group using conventional metal wires: group N (86 patients: M 65, F 21) and group O (69 patients: M 50, F 19). Preoperative factors included age at surgery (group N: group O)=68.4±10.6 : 69.6±11.5 years (p=0.25)), BMI (group N: group O=23.0±3.7 : 24.1±7.7 (p=0.16)) and HbA1c (group N: group O=6.3±1.1 : 8.0±10.3% (p=0.10), and no factors were significantly different between the two groups. The CT analysis at the point of hospital discharge after surgery measured postoperative sternal deviation in the third rib position. Transverse displacement was significantly reduced (group N: group O=0.22±0.73: 0.83±1.08 mm (p=0.005)), and longitudinal displacement also showed an improvement but the difference was not statistically significant (group N: group O=0.53±0.86: 0.72±1.14 mm (p=0.13). Conclusion: A novel sternum closing technique using a tension-anchored titanium cable and a PLA mesh plate demonstrated improved postoperative sternal fixation in a controlled study with 155 patients. This new procedure also enables standardized stable sternal closure with a constant force without relying on conventional empirical sensation and without suppressing sternal cutting, thus contributing to the improvement of postoperative quality of life and prevention of complications.