The patient was a 65-year-old man who had undergone AVR (SJM Regent : 19 mm) for AR in June 2007. Since March 2008 there had been an increase in the pressure gradient between the aorta and the left ventricle on transthoracic echocardiography (peak PG : 46 mmHg, mean PG : 27 mm Hg). Plain x-ray films of the valve showed limited opening of the metallic valve. However, no symptoms of heart failure were observed on a physical examination. Blood tests performed in December 2007 showed a PT-INR value of 1.22. Since the effects of warfarin anticoagulant therapy were insufficient, its dose was adjusted on follow-up. An examination in June revealed further stenosis of the valve (peak PG : 93 mmHg, mean PG : 58 mmHg). Valve thrombosis was suspected because the condition was poorly controlled by warfarin. Thus, thrombolytic therapy using t-PA was performed (800,000 units). However, the patient complained of chest pain 1 h 30 min after initiation of thrombolytic therapy. Twelve-lead electrocardiography was performed, and ST-segment elevations were observed in the limb and chest leads. Acute myocardial infarction due to a free-floating thrombus was suspected, and emergency cardiac catheterization was performed. Segment 7 was totally occluded, and reperfusion was achieved by thrombus aspiration. Embolization of the coronary artery was speculated to have occurred because of the improved mobility of the metallic valve and dissolution of a thrombus adhering to the valve. A case of acute myocardial infarction as a complication of thrombolytic therapy for valve thrombosis is rare. This case reaffirms the necessity of careful monitoring during thrombolytic therapy.

A 54-year-old man was admitted to our hospital because of hypertrophic obstructive cardiomyopathy (HOCM). Medical treatment was not effective. Cardiac catheterization showed a peak systolic pressure gradient of 143mmHg between the left ventricle and the ascending aorta. Echocardiogram showed a systolic anterior motion and moderate mitral regurgitation without asymmetric septal hypertrophy. He underwent mitral valve replacement (MVR) with a 27-mm SJM instead of myectomy due to his relatively thin ventricular septum of 16mm. Postoperative cardiac catheterization revealed no significant pressure gradient between the left ventricle and the ascending aorta. MVR is the most effective surgical treatment of HOCM without asymmetric septal hypertrophy.

A 45-year-old woman was admitted for acute left hemiplegia and left hypogastric pain. Central CT showed a right parietal lobe infarction. Abdominal CT demonstrated ovarian tumor and infarction of the liver, spleen and kidney. Chest radiography showed moderate cardiomegaly. Transthoracic echocardiography demonstrated vegetation in the aortic valves and severe aortic regurgitation. Aortic valve replacement and bi-adnexectomy were performed urgently. Intraoperative examination revealed normal aortic valves except for small amounts of vegetation on leaflet surfaces. Pathological diagnosis of vegetation was fibrin without inflammatory cells or bacteria. The postoperative course was uneventful, and the patient was discharged 13 days after surgery without a permanent neurological deficit. Trousseau syndrome caused by ovarian cancer and nonbacterial thrombotic endocarditis is rare, and it is important to be aware of this syndrome in the case of a young cerebral infarction patient with malignant disease.

A 73-year-old man presented with gastric adenocarcinoma 14 months after coronary artery bypass grafting with an in situ right gastroepiploic artery (RGEA) to left circumflex branch (LCx). He underwent a partial gastrectomy after successful percutaneous coronary intervention (PCI) to the occluded lesion of LCx. Though the RGEA graft was injured and sacrificed intraoperatively, gastrectomy was safely accomplished without any complication and the postoperative course was uneventful. Preoperative PCI was useful for a gastrectomy in a patient with an in situ RGEA.

Background: Palliative care has been advocated to be administered in the early phase of cancer treatment. However, little is known concerning the recognition of palliative care in general citizens. We have conducted promotional activities for palliative care as “Nonohana Project” since 2009. The aim of the current study was to investigate the awareness of palliative care in the general public in Okayama Prefecture. Methods: We performed telephone questionnaire survey about palliative care for a total of 600 general citizens aged 20 or over in Okayama Prefecture. This survey was conducted in 2009 and 2010, and we compared those results. Results: Two hundred twenty four people (37.3%) have heard of the phrase “palliative care” in 2009 and 219 people (36.5%) in 2010. The recognition of palliative care stayed at the same level as in the previous fiscal year. In those with a history of cancer of themselves or their family, the recognition was slightly increased (41.6% in 2009 and 43.2% in 2010). There were many people who were interested in palliative care in both 2009 (87.9%) and 2010 (86.3%). Conclusion: Our study indicated that many people still had no idea of palliative care in Okayama Prefecture, despite of our promotion and effort for 1 year. However, many were interested in palliative care, suggesting a need for continuous promotion to increase the understanding of palliative care.

A 24-year-old man was transferred to our hospital because of traumatic rupture of the thoracic aorta suffered in a traffic accident. On admission, he had recovered from shock and was alert. Chest CT showed massive hematoma around the total extent of the descending aora and the intimal flap at the diatal descending aorta. We performed an emergency operation. Through left thoracotomy, we found dilatation of the descending aorta. Epiaortic echo revealed that the aortic intima was completely transecred between Th 10 and Th 11. The pseudoaneurysm was replaced with a Hemashield vascular graft under partial cardiopulmonary bypass. The intercostal artery was preserved. His postoperative course was uneventful and paraplegia was not seen. We reported a rare case of traumatic rupture of the distal descending thoracic aorta above the diaphragm followed by successful surgical treatment.

A 61-year-old man underwent percutaneous coronary intervention (PCI) for the right coronary artery. However, he had an acute onset of right neck pain and swelling after PCI. Contrast enhanced computed tomography (CT) revealed extravasation into the mediastinum and aberrant right subclavian artery. After transfer to our hospital, we performed emergency endovascular repair for iatrogenic arterial injury. His postoperative course was uneventful.

Central diabetes insipidus (CDI) is a disease that caused by insufficient or no anti-diuretic hormone (ADH) secretion from the posterior pituitary, which results in an increase in urine volume. CDI is controlled with ADH supplementation thereby reducing urine output and correcting electrolyte imbalance. However, reports on perioperative management for CDI patient are scarce, especially for patients who underwent cardiac surgery. We herein report our experience of the management of a CDI patient who underwent surgery for valvular heart disease.

The case is a 72-year-old woman who developed secondary CDI after pituitary tumor removal. She had been controlled with orally administered desmopressin acetate hydrochloride. She underwent aortic valve replacement and mitral valve repair for severe aortic, and moderate mitral regurgitation. Immediately after surgery, we started vasopressin div, which yielded good urine volume control. However, once we started to switch vasopressin to oral desmopressin administration, the control became worse. We thus made a sliding scale for subcutaneous injection of vasopressin every 8 h according to the amount of urine output, which resulted in good control. Overlapping administration of vasopressin and oral desmopressin between postoperative day 12 and 17 resulted in successful transition. The patient was discharged with oral desmopressin administration. Management with sliding scale for vasopressin subcutaneous injection after surgery was useful in controlling a CDI patient who underwent major cardiac surgery.

The patient was an 81-year-old woman who had undergone TAVI (Evolut PRO® 26 mm) for severe aortic stenosis at our hospital approximately 6 months previously. She was discharged from the hospital without any postoperative complications, but at 6 months after the surgery, fever, back pain, and high inflammatory findings were observed. Based on lumbar spine MRI findings, the patient was diagnosed with pyogenic spondylitis and epidural abscess, and drainage surgery was performed. Enterococcus faecalis was identified from a blood culture. MRI of the head showed scattered subacute infarcts in the right frontal lobe, and transthoracic echocardiography revealed hyperintense deposits at the aortic valve leaflet, suggesting vegetation. The diagnosis of PVE was made and medical therapy was initiated. However, the vegetation gradually increased in size and mobility, and a surgical approach was indicated. A surgical procedure was performed through a median sternotomy to remove the prosthetic valve and replace the aortic valve. The postoperative course was good, with no recurrence of infection, and the patient was transferred to another hospital for rehabilitation on the 26th postoperative day. In general, TAVI patients are older and have more comorbidities, and surgery is associated with a higher degree of risk. However, radical surgery should be considered if medical therapy is not effective in PVE after TAVI. We reported a case of surgical aortic valve replacement for PVE after TAVI.