An 82-year-old man was referred to our hospital for heart failure due to severe mitral regurgitation and severe tricuspid regurgitation. We performed mitral annuloplasty and tricuspid annuloplasty (TAP). Three weeks after surgery, he developed hemolytic anemia (HA). Transesophageal echocardiography revealed a defect in the left ventricular outflow tract that communicated directly with right atrium, and the jet was striking with the TAP prosthetic ring. HA was not controlled, so we performed re-operation. The defect was found in the atrioventricular membranous septum. The defect was closed and TAP was performed using an autologous pericardial roll again. We report a rare case of acquired left ventricular to right atrium communication after TAP.

A 16-year-old boy had a motorcycle accident and was given a diagnosis of blunt aortic injury (BAI) by contrast computed tomography (CT), complicated by diffuse brain injury, lung contusions and blunt liver injury. Despite conservative treatment his anemia worsened and further CT images revealed mediastinal hematoma. It was difficult to perform cardiopulmonary bypass with systemic heparinization because of his multiple injuries and therefore decided to perform endovascular stentgrafting. Aortography revealed that the proximal stent-graft landing zone to be very small, and therefore it was necessary to the cover left common carotid artery. Before stentgrafting, we performed a right subclavian artery-left common carotid artery bypass to attain a sufficient proximal landing zone, and stentgrafting was successful. We concluded that endovascular stentgrafting is an effective initial treatment for BAI complicated with multiple injuries. However, endovascular stentgrafting for BAI has some limitations because of the morphologic and anatomical characteristics of the thoracic aorta in cases of BAI. It is therefore important to perform endovascular stentgrafting for BAI on a case-by-case basis.

We present a successfully treated case of re-operation for aortic valvular stenosis caused by implantation of a stentless prosthesis using oversizing sub-coronary insertion in a young woman. The 17-year-old Japanese woman received aortic valve replacement (AVR) with a 21mm Freestyle stentless porcine valve (Medtronic Inc.), using the oversizing modified sub-coronary insertion because of infectious endocarditis 12 years previously at another hospital. Just after the operation, she suffered severe heart failure. At 16 years old, since a cardiac murmur and dyspnea on effort appeared, and she presented severe heart failure due to significant aortic valvular stenosis with a mean aortic valve gradient 115mmHg, we performed aortic valve re-replacement (ATS AP 18mm) with an aortic root enlargement procedure. Intraoperative findings suggested that the oversizing technique was related to aortic valvular stenosis. The postoperative course has been uneventful.

A 24-year-old man was admitted to another hospital due to fever and chest and back pain. Enhanced chest computed tomography showed an aneurysm between the distal aortic arch and left pulmonary artery. The patient was transferred to our hospital for surgery. Because of suspicion of an infectious ductus arteriosus aneurysm, antibiotic therapy was started. Urgent graft replacement of the descending aorta was performed on the third day due to the enlargement of the aneurysm. All blood cultures including the preoperative examination, and the aneurysmal culture were negative. The histopathological study showed non-specific inflammatory response with plasma cell, T lymphocyte, and B lymphocyte infiltrations. There was no evidence of infection. Eventually we diagnosed this patient as having a ductus arteriosus aneurysm with non-specific inflammation. The antibiotic therapy was terminated on postoperative day 10, and the postoperative course was uneventful.

A 41-years-old man with Marfan syndrome developed acute aortic dissection Stanford Type B. A new entry was located at the distal aortic arch. Medical treatment was given for a month, but the proximal descending aorta expanded to 50 mm. Because he had undergone partial arch replacement at the age of 36, thoracic endovascular aortic repair (TEVAR) using the synthetic graft as proximal landing zone was performed to close the entry. Six months after TEVAR, the false lumen around the stent graft disappeared. Distal stent graft-induced new entry (d-SINE) did not occur after TEVAR. Three years after TEVAR, we performed thoracoabdominal aortic replacement because of expansion of the residual false lumen without any complication. Endovascular therapy could be useful option for extensive aortic lesion even in Marfan syndrome.

We report the case of a patient with severe tricuspid regurgitation and severe liver dysfunction who was successfully treated by tricuspid valve repair with spiral suspension and perioperative management of high cardiac output. The patient was a 77-year-old woman who presented with chronic atrial fibrillation with bradycardia (heart rate approximately 50 bpm). She had been diagnosed with severe tricuspid valve and mitral valve regurgitation at the age of 74. As her heart failure and hepatic failure grew worse, and hepatic encephalopathy also occurred, she was admitted to the hospital. Her Child-Pugh score for liver disease was Grade C at the preoperative assessment, suggesting that she was in the high-risk category for open heart surgery. Therefore, further medical treatment was required before selecting the surgical treatment. After the implantation of a pacemaker (VVI mode, 80 bpm), the cardiac output increased with a cardiac index of 5.17 L/min/m2 compared with 2.97 L/min/m2 prior to pacemaker implantation. Furthermore, the symptoms of heart failure improved and total bilirubin decreased from 3.9 mg/dl to 1.7 mg/dl, and surgery was performed. Tricuspid regurgitation was treated with spiral suspension, and mitral regurgitation due to annular dilation was treated with annuloplasty. Following the surgery, the cardiac index was maintained from 4.3 L/min/m2 to 5.8 L/min/m2 with central venous pressure below 10 mmHg by the assistance of intra-aortic balloon pumping. The patient was extubated 30 h after surgery, and was discharged on postoperative day 54. At the time of discharge, total bilirubin was 1.5 mg/dl. At 1.5 post-operative years, the patient is New York Heart Association functional Class II and tricuspid valve regurgitation is mild.

A 73-year-old man had been followed up in our hospital after surgery for mitral regurgitation. At the age of 67, he underwent mitral valve plasty through a right mini-thoracotomy approach for atrial functional mitral regurgitation at our hospital. The mean trans-mitral pressure gradient was 5 mmHg after surgery but no heart failure symptoms were observed. At the age of 72, he began to notice fatigue during exertion. Transthoracic echocardiography revealed that the mitral valve regurgitation was controlled to a trace level, but the mean trans-mitral pressure gradient increased to 10 mmHg. Transesophageal echocardiography and contrast-enhanced cardiac computed tomography revealed the restricted opening of the mitral valve and pannus formation around the prosthetic ring. We thus diagnosed mitral stenosis due to pannus overgrowth. He underwent pannus excision and removal of the artificial ring. Postoperative echocardiography revealed that the mean trans-mitral pressure gradient was reduced to 3 mmHg and no residual mitral regurgitation was observed. He was discharged on postoperative day 11 with no major symptoms. He was in New York Heart Association functional class I at 1 year after the surgery and continues to be an outpatient.

A 74-year-old woman was scheduled for total arch replacement because of an enlarging thoracic aortic aneurysm in the aortic arch. Her preoperative blood test showed an elevated cold agglutinin with a titre of 2,048. There was concern about hemagglutination during hypothermia and hemolysis when returning to natural temperature under hypothermic circulatory arrest. We usually use moderate hypothermia (a minimum rectal temperature of 27℃) with circulatory arrest during total arch replacement. A cooling test was performed with her blood, which found no coagulation reaction in vitro at 25℃. There was a possibility that the total arch replacement would be carried out under moderate hypothermia, but it was by no means certain. After discussing the case with the hematologist, anesthetist, and clinical engineer, we decided on a minimum temperature of 30℃ during circulatory arrest because hemagglutination or hemolysis can become an issue in cardiopulmonary bypass. Coronary perfusion was maintained by infusing blood cardioplegia at 30℃ every 30 min. The intra-aortic occlusion balloon was inflated in the descending aorta, and perfusion of the spinal cord and lower body was initiated via the left femoral artery during circulatory arrest. Total selective cerebral perfusion flow was maintained at 1.5 times normal (20 ml/kg/min). There was no hemagglutination or hemolysis during the operation and no neurological complications in the postoperative period. For patients with cold agglutinin, individual cardiopulmonary bypass planning is necessary, depending on the severity of the condition and operative method.