A baby girl with a low birth weight was given a diagnosis of congenital bicuspid aortic stenosis and mitral valve prolapse. At the age of 40 days, she underwent balloon aortic valvotomy, but significant aortic regurgitation appeared afterwards. Another surgical intervention became necessary by the age of 20 months (weight, 5.7 kg), because of intractable heart failure mostly caused by exacerbated mitral regurgitation. We performed a leaflet extension valvuloplasty for the small bicuspid aortic valve using an autologous pericardium treated by glutaraldehyde. The mitral valve was replaced with an ATS-16AP valve. Although her postoperative course was complicated with mitral paravalvular leakage and poor left ventricular function, she was discharged from hospital 6 months post operatevely. Leaflet extension valvuloplasty is a surgical option for infants with a small aortic annulus, but the procedure could be the only solution in cases when Konno or Ross techniques are not suitable.

Late acute type A aortic dissection after coronary artery bypass grafting (CABG) is rare, and only a few cases have been published in the literature. It is important to treat cases of living graft during reoperation. We report a successful surgical treatment in a case of late acute type A aortic dissection after CABG. A 68-year-old man underwent a triple CABG (to the left anterior descending artery with left internal thoracic artery, to the left circumflex artery with left radial artery, and to the right coronary artery with right gastroepiploic artery) beating heart procedure using a centrifugal pump and pulmonary assist with closed circuit due to unstable angina pectoris in December 2007 and had presented with sudden anterior chest pain, and was found to have an ascending aortic dissection (type A) on enhanced computed tomography in May, 2009. We performed ascending artery replacement, paying special attention to the living graft performed through a median sternotomy. The postoperative course was uneventful and he was discharged on the 22nd postoperative day.

A 79-year-old woman with degenerative mitral regurgitation and secondary tricuspid regurgitation underwent mitral and tricuspid repair. Massive and intractable endobronchial hemorrhage occurred during weaning from cardiopulmonary bypass (CPB). Bronchoscopic examination during CPB revealed that the right distal bronchus was the probable bleeding point. We then performed a double-lumen endotracheal tube and a bronchial blocker in the distal portion of the right main bronchus. In addition, extracorporeal membrane oxygenation (ECMO) with a heparin-coating system was performed for 11 h, without extra heparinization because of severe hypoxia. The bronchial blocker was removed 14 h later, and the patient was weaned from ECMO 19 h after admission into ICU. Postoperative computed tomography (CT) revealed a pseudoaneurysm of the right pulmonary artery (A⁵b) corresponding with the probable site of bronchial bleeding (B⁵). We speculate that a pulmonary artery catheter induced this endobronchial hemorrhage. At 3 months after surgery the patient was doing well with no symptoms of airway bleeding, and her abnormal CT findings had disappeared.

Infectious endocarditis (IE) concomitant with patent ductus arteriosus (PDA) is now considered rare because the early treatment of PDA in infancy has become standard. We report a case of PDA with IE diagnosed by computed tomography (CT). A 51-year-old man complained of arthralgia and numbness of the left extremities. He had fever of 39°C and left hemiplegia, and was referred to our hospital. A chest X-ray film showed infiltration in both lungs. CT revealed a mass lesion in the main pulmonary artery and a tubular connection between the main pulmonary artery and the aortic arch. Multiple small infarctions were also found in the brain, lungs, kidneys and spleen. Ultrasonic cardiography revealed a bi-leaflet aortic valve, and vegetations on the aortic and mitral valves. Staphylococcus aureus was detected by culture of an intravenous catheter tip. These findings suggested IE concomitant with PDA, and we started intravenous administration of antibiotics. However, congestive heart failure occurred due to severe aortic and mitral regurgitation 2 days after hospital admission, and therefore, we performed emergency surgery. The main pulmonary artery was incised after cardiopulmonary bypass was initiated. A 20-mm length of vegetation was found on the orifice of the PDA. The vegetation was removed and the PDA directly closed. Aortic and mitral valve replacement was then performed. The post-operative course was uneventful and his neurological symptoms did not exacerbate. No sign of IE recurrence was observed 2 years after the surgery. CT clearly showed PDA and vegetation in the main pulmonary artery, although ultrasonic cardiography did not. CT was useful to make a diagnosis of PDA with IE in the present case.

In 306 patients who underwent elective coronary artery bypass graft (CABG) between January 2005 and July 2008, low cardiac functions (EF<35%) were seen in 24 patients. Of these, 7 (EF, 22.7±5.4%, NYHA 3.4±0.4) had a left ventricular epicardial lead implanted during surgery. On completion of bypass anastomosis, a screw-in-type epicardial lead was implanted. The mean threshold at implantation was satisfactory (1.1±0.4 V). There were no complications related to intraoperative lead placement. In the aforementioned 7 patients, combined Cardiac resynchronization therapy defibrillator (CRT-D) implantation was performed in 4 during the postoperative period while they were still in the hospital. In 1 other patient, the procedure was conducted when he was readmitted for heart failure 3 months after discharge. The threshold for the left ventricular myocardial lead was satisfactory (1.0±0.1 V). No postoperative complications, such as infections, hemorrhage, or twitching, were noted. For those patients who are likely to have a CRT-D placed after CABG, a left ventricular lead showed be implanted if possible for the safe and fast postoperative placemens of a defibrillator. However, the indications of myocardial lead implantation must be considered carefully.

The objective of this study was to evaluate the inflammatory responses in patients who received 1 of 2 different types of woven Dacron grafts. Abdominal aortic surgery was performed in 154 patients between 2002 and 2006, and 102 patients were enrolled in this study. Sealed woven Dacron grafts (INTERGARD^TM woven graft, Group I) were implanted in 77 patients and non-sealed woven Dacron grafts (UBE woven graft, Group N) were implanted in 25 patients. All patients received either a bifurcated graft or straight graft replacement. Body temperature (BT), white blood cell counts (WBC), and C-reactive protein (CRP) levels were measured preoperatively and on postoperative days 1, 3, 5, 7 and 14, and were compared between the 2 groups. There were no differences in the patient's mean ages, 73±9 and 71±7 years, or operation time, 213±57 and 210±63 min, between Groups I and N, respectively. Postoperative changes in BT and WBC were similar in both groups. CRP levels were higher in Group N than Group I on postoperative days 5 and 7, but these differences were clinically insignificant. Prolonged inflammatory response which lasted longer than 2 weeks occurred in 2 patients in Group I and in 1 patient in Group N. All patients eventually returned to baseline conditions without special treatments. Thus the postoperative inflammatory responses to coated and non-coated woven Dacron grafts were similar in abdominal aortic surgery.

Systemic inflammation after cardiac surgery using cardiopulmonary bypass (CPB), is closely associated with postoperative organ dysfunction. We evaluated the efficacy of continuous hemodiafiltration (CHDF) in controlling postoperative organ dysfunction, focusing on serum inflammatory substances and organ protection. We enrolled 14 patients with postoperative circulatory collapse. The mean age of patients was 71 years. Heart valve surgery was performed in 9 patients, coronary artery bypass grafting in 5 and graft replacement of the thoracic aorta in 2. The mean CPB time was 297±28 min. CHDF was initiated on the first or second postoperative day in 12 patients. A polysulfone membrane dialyzer and nafamostat mesilate were used for CHDF. 1) On blood examinations, serum IL-6 and IL-8 concentrations decreased 12 h after the initiation of CHDF (216±50→92±27 pg/dl, 71±23→30±7 pg/dl, respectively). Serum aldosterone decreased at 12 h (144±20→104±21 pg/ml). Four hours after the initiation of CHDF, systemic blood pressure significantly increased from 94±6 to 123±6 mmHg. The systemic vascular resistance index significantly increased from 1,431±137 dyn·sec·cm^-5·m² to 1,893±167. Urine volume significantly increased from 42±38 to 100±29 ml/h. Serum creatinine decreased from 2.1±0.3 mg/dl to 1.7±0.2 mg/dl on the second day. Respiratory function had significantly improved at 24 h. Early induction of CHDF reduced serum inflammatory substances, resulting in quick circulatory recovery without organ failure.

This study aimed to clarify whether continuous hemodiafiltration (CHDF) or hemodialysis (HD) was more effective after open heart surgery in dialysis patients. We evaluated 48 consecutive hemodialysis patients (28 men and 20 women, mean age : 68±10 years) who underwent coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) between January 2003 and December 2008. The patients were divided into 2 groups according to their postoperative dialysis treatment either continuous hemodiafiltration (CHDF) (CHDF group, n=36) or hemodialysis (HD) (HD group, n=12). Surgery in the CHDF group included 13 concomitant operations, 16 CABGs and 7 AVRs. There was only 1 concomitant surgery in the HD group, and there were 6 CABGs and 5 AVRs. There was no difference between the 2 groups regarding operation time, aortic clamp time, cardiopulmonary bypass time or intraoperative volume balance. CHDF was started significantly earlier than HD (8.0±5.8 vs. 21.0±1.0 h, p <0.01), which resulted in the removal of a greater volume of body fluid, during the first postoperative 24 h in the CHDF group (1,200±110 vs. 550±50 ml, p <0.01). However, there was no difference between the 2 groups regarding the amount of postoperative chest drainage. There were 6 hospital deaths in the CHDF group (17% ; 3 heart failures, and 1 each of pneumonia, arrhythmia and massive intestinal necrosis). There was also 1 hospital death in the HD group (8.3% ; heart failure). Most of the hospital deaths occurred after concomitant operations (6/7, 86%). It is beneficial to start CHDF soon after open heart surgery in hemodialysis patients.

A 51-year-old man admitted to our hospital because of an ECG abnormality pointed out by his local doctor. He had been hospitalized for scarlet fever at age 10. A coronary artery CT scan showed coronary artery aneurysm of the left main trunk (LMT), and coronary angiography showed 3-vessel disease including a chronic total occlusion of the right coronary artery (RCA). We performed conventional coronary artery bypass grafting (CABG) using an arterial graft and aneurysmectomy. The patency of the graft was confirmed by coronary angiography postoperatively. The pathological diagnosis of the coronary aneurysm was Kawasaki disease. CABG is a standard procedure for coronary artery aneurysms with Kawasaki disease. However, there are no established treatment guidelines on whether to perform aneurysmectomy. We chose CABG with aneurysmectomy because of the possibility of intra-aneurysmal thrombosis leading to peripheral occlusion, and the cause of the coronary artery aneurysm could not be determined. However, even if additional treatment by percutaneous coronary intervention (PCI) is not possible, it is important to avoid occlusion of the graft.

A 58-year-old man presented with hydrothorax, an irregular heart rate, and symptoms of heart failure approximately equivalent to the New York Heart Association (NYHA) class 2. Echocardiographic and cardiac catheterization findings suggested constrictive pericarditis, but CT scans revealed only slight thickening of the pericardium. He had liver cirrhosis, to the extent that surgery appeared to be high risk in this case. The patient was thus managed medically but showed no tendency fowards improvement despite 6 months of treatment. He was then given a diagnosis of having hepatic dysfunction due to a congestive liver associated with constrictive pericarditis. Pericardiectomy was then performed. Postoperatively, his hepatic function improved markedly and his symptoms disappeared. This case is described, with reference to the literature.